Hospital Coverage Claim Report Form
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1
2MedCASH Plan
P.O. Box 17410
Denver, CO 80217-0410
1-866-257-0707 – Tel
1-303-737-2879 – Fax
HOSPITAL COVERAGE CLAIM REPORT
MEMBER STATEMENT – PLAN #1107
INSTRUCTIONS: Complete all questions, date and sign Authorization Section and attach a copy of your itemized bill showing
room and board charges. YOUR BILL MUST INCLUDE A DIAGNOSIS OR YOU MUST HAVE YOUR DOCTOR SUBMIT A
STATEMENT VERIFYING YOUR DIAGNOSIS. If you do not have a bill to submit, contact the patient billing department at the
hospital and request the itemized UB-04 form be sent to you. Please note: If you wish to file a claim for Critical Condition
benefits separate claim forms are required.
1. Members Name: ________________________________________ 2. ADA No. __________________________
3. Sex:
Male
Female
4. Date of Birth:
____/____/____
5. Home Address (No., Street, City, State, Zip): _______________________________________________________
_____________________________________________________________________________________________
6. Home Phone Number: _(_____)__________________
7. Office Phone Number: _(_____)_________________
If making a hospitalization claim for Spouse or Dependent, please list:
a.) Spouse / Dependent’s Full Name: _______________________________________________________________
b.) Relationship to member: ______________________________________________________________________
c.) Date of Birth: ____/____/____
d.) Sex
Male
Female
e.) Is Spouse / Dependent employed?
Yes
No
f.) Employer’s Name and address: _________________________________________________________________
g.) Is Dependent a full time student?
Yes
No
h.) Is Dependent married?
Yes
No
8. When did injury occur or when did illness commence? Date: ____/____/____ at: _________________ AM/PM
9. Describe injury, illness, and/or medical reasons for your hospital visit by means of a diagnosis: _______________
_____________________________________________________________________________________________
10. Name, address and telephone number of all physician(s) treating this condition including Primary Care physician
(Please attach additional pages if necessary) :
____________________________________________________________________________________________
_____________________________________________________________________________________________
11. If hospitalized, give name, address and telephone number of hospital(s):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
12. Dates of Service: 1) Start date ____/____/____ to: End date ____/____/____
2) Start date ____/____/____ to: End date ____/____/____
13. Has the person making claim ever received any medical treatment, care, advice or medication for the same or
related condition?
Yes
No If yes, please provide details:
_____________________________________________________________________________________________
______________________________________________________________________
PLEASE SIGN AND DATE AUTHORIZATION ON BACK SIDE
M 4022 (09/12)
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