Form 7190 - Horizon Traditional And Ppo Health Insurance Claim Form
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Horizon Traditional and PPO Health Insurance Claim Form
Please Print This Form In Color (If Available).
THIS FORM CAN BE DOWNLOADED FROM OUR WEB SITE AT
INSURED’S INFORMATION
1. LAST NAME
FIRST NAME
MI
2. DATE OF BIRTH
3. SEX
4. IDENTIFICATION NUMBER
/
/
M
F
MM
DD
YYYY
Prefix (if any)
Number Portion
. 6
A
D
D
R
E
S
S
C
T I
Y
S
T
A
T
E
Z
P I
C
O
D
E
(No., Street)
8. EMPLOYER’S NAME
7. TELEPHONE NUMBER
(Include Area Code)
9. INSURANCE PLAN NAME OR PROGRAM NAME
10. IS THERE ANOTHER INSURANCE PLAN?
IF YES, COMPLETE
ITEMS 20 - 26
No
Yes
PATIENT’S INFORMATION
(If Patient is the same as the Insured, please skip to #16)
11. LAST NAME
F
R I
S
T
N
A
M
E
M
I
12. DATE OF BIRTH
13. SEX
14. TELEPHONE NUMBER
/
/
M
F
MM
DD
YYYY
(Include Area Code)
1
. 5
A
D
D
R
E
S
S
C
T I
Y
S
T
A
T
E
Z
P I
C
O
D
E
(No., Street)
16. RELATIONSHIP TO INSURED
17. PATIENT’S STATUS
EMPLOYED
FULL-TIME STUDENT
PART-TIME STUDENT
Self
Spouse/DP
Child
Other
Single
Married
Other
18. IS PATIENT’S CONDITION RELATED TO:
19. DATE OF CURRENT ILLNESS
ILLNESS (First symptom) OR
INJURY (Accident) OR
a. EMPLOYMENT?
b. AUTO ACCIDENT?
PLACE (State)
C. OTHER ACCIDENT
(Current or Previous)
/
/
PREGNANCY (LMP)
No
Yes
N
o
Y
e
s
N
o
Y
e
s
MM
DD
YYYY
OTHER INSURANCE INFORMATION
20. LAST NAME OF POLICY HOLDER
FIRST NAME
MI
21. DATE OF BIRTH
22. SEX
23. IDENTIFICATION NUMBER
/
/
MM
DD
YYYY
M
F
25. EMPLOYER’S NAME OR SCHOOL NAME
24. TELEPHONE NUMBER
(Include Area Code)
26. INSURANCE PLAN NAME OR PROGRAM NAME
AUTHORIZATION
27.I certify that the information provided on this claim form is correct and complete, and that I am claiming benefits only for charges actually incurred by the patient named.
I authorize any hospital, physician or other provider who participated in the care and treatment of the patient to release to Horizon Blue Cross Blue Shield of New Jersey
all medical or other information requested for the processing of this claim form. I hereby agree to reimburse Horizon Blue Cross Blue Shield of New Jersey, in full should
this claim be incorrectly paid.
/
/
28.
SIGNATURE OF PATIENT (unless a minor)
DATE
28. AUTHORIZATION FOR ASSIGNMENT OF BENEFITS
29.
Horizon Blue Cross Blue Shield of New Jersey, at its discretion, may accept an Assignment of Benefits. I the undersigned, authorize and request Horizon Blue Cross Blue
Shield of New Jersey, to make payment for benefits which may be due herein to:
NAME OF HEALTH CARE PROFESSIONAL
TAX NUMBER (Required)
NPI NUMBER
/
/
SIGNATURE OF INSURED
DATE
SEE BACK OF THIS FORM FOR IMPORTANT INFORMATION
An Independent Licensee of the Blue Cross and Blue Shield Association
7190 (W0609)
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Parent category: Business