Bcbs Coordination Of Benefits Questionnaire Page 2
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2Coordination of Benefits Questionnaire
Section B
If this does not apply, skip to Section C.
M
I
EDICARE
NFORMATION
Do the policyholder and/or dependent(s) have Medicare?
Yes
No
Name of person(s) with Medicare: ____________________________
Medicare Number, including alpha character(s): ________________________
Effective Date of Medicare Part A ____/____/______ Effective date of Medicare Part B: ____/____/______
Effective Date of Medicare Part D ____/____/______
Medicare Entitlement:
Age
Disability*
End Stage Renal Disease (ESRD)*
* If the reason is for Disability or ESRD, please provide the following:
st
1
Date of Disability: ____/____/______
st
1
Date of Dialysis for ESRD: ____/____/______
Was ESRD started in a facility?
Yes
No
Was ESRD started as Self Dialysis or Home Dialysis:
Yes
No
Has a transplant been performed?
Yes
No
If yes, please provide the date of the transplant. ____/____/______
Section C
If this does not apply, skip to Section D.
C
O
I
OURT
RDER
NFORMATION
Is there a Court Order specifying a person(s) to maintain health coverage for any of your dependent(s)?
No
Yes
List the name(s) of the dependent(s) that this applies to. _________________________________________
If yes, who is the person(s) listed to maintain health coverage? ____________________________
What is the relation to the child(ren)? ____________________________
Who has custody of the child(ren) more than 50% of the time? ____________________________
Documentation of the court order may be requested from your Blue Cross Blue Shield plan.
Section D
N
(
)
D
(
)
BCBS P
AME
S
OF
EPENDENT
S
ON
OLICY
Name
Relationship
Date of Birth
Sex
Social Security # (Optional)
__________________
____________
____/____/______
____
_____-____-_______
__________________
____________
____/____/______
____
_____-____-_______
__________________
____________
____/____/______
____
_____-____-_______
Policyholder Signature: _______________________________________ Date: ____/____/______
10-06
Page 2
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