Member Medical Reimbursement Claim Form
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2MEMBER MEDICAL REIMBURSEMENT CLAIM FORM
Instructions for Submitting Claims
1. Submit a claim only when you are billed for services from a provider that does not directly submit a claim to Harbor Choice.
2. Submit a separate form for each patient.
3. Attach an original itemized bill from your provider (required information is on the second page of this form).
4. Keep a copy of all bills and claim forms submitted (originals will not be returned).
5. Be sure to sign and date the completed form.
6. A member will be reimbursed for a covered health service for which he/she is required to make full payment at time of service.
For claims to considered for reimbursement by Harbor Choice, they must meet the member’s package criteria. (If a service is
obtained that is normally not a covered benefit under the member’s benefit package, it would not be a service eligible for
reimbursement.) Refer to your “Evidence of Coverage” (EOC) for details of your benefits package.
7. Mail this claim form and all attachments to:
Harbor Choice Claims
c/o – Conifer Value-Based Care
P.O. BOX 6752
Annapolis, MD 21401
Requested Reimbursement Amount $_____________
Subscriber (plan holder) Information
Member ID Number___________________
Member Last Name _____________________ Member First Name _____________________
Member Address (street number/name) ______________________________ City ___________________ State ____ Zip Code __________
Member Date of Birth (MM/DD/YYYY) ___/___/______
Patient Information
Patient Last Name _________________ First Name________________ Middle Initial ____ Date of Birth (MM/DD/YY)___/___/______
Gender:
Male
Female
Patient is:
Subscriber (plan holder)
Child/Dependent
Spouse (of plan holder)
Other (specify)_____________________________________________
Secondary Coverage
Was the treatment for…
Does the patient have other insurance?
Yes
No
An accident at work?
No
Yes, date of accident ________________
If yes:
Auto accident?
No
Yes, date of accident ____________________
Medicare Part A (Hospital) _________________________ If yes, name of auto insurance___________________________________
Medicare Part B (Medical) _________________________
Auto insurance policy number___________________________________
Medicare Part A (Pharmacy ________________________
Other accident?
No
Yes, date of accident____________________
Other Insurance Plan______________________________ Please explain the nature of the accident __________________________
Identification number on other insurance plan:___________________________________________________________________________
Name and address of other insurance:______________________ ____________________________________________________________
I authorize the release of any medical or other information necessary to process this claim
Subscriber (plan holder) Signature
Date:
_________________________________________________________
______________________________________
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Updated Jan. 2016
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