Coordination Of Benefits Questionnaire - Anthem Blue Cross And Blue Shield And Its Affiliated Hmos - 2009
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1Anthem Blue Cross and Blue Shield and Its Affiliated HMOs
COORDINATION of BENEFITS QUESTIONNAIRE
Covered Person’s Name _______________________ Covered Person’s Identification Number _______________
Are you, your spouse or any dependent(s) covered by another health insurance plan or Medicare? (If the only other coverage is
Tricare or Medicaid please check NO)
NO___ (If no one on this policy is covered by any other insurance or Medicare, please skip to Section 3)
YES___ (If YES, compile Section 1 for other insurance carriers and Section 2 for Medicare policies)
SECTION 1 – OTHER HEALTH INSURANCE OR HEALTH PLAN INFORMATION
If you answered YES to the question above, please refer to the other carrier’s insurance card to complete this section and/or the
Medicare section if applicable.
(A) Other Insurance Covered Person’s name ________________________ Date of Birth ___/___/___ Policy No.:_____________
(B) Health Insurance Company name or name of group health plan ______________________________ Insurer or
Administrator’s Phone # (___)___________Group # ___________ Effective Date: ___/___/___ Cancel date: ___/___/___
(C) Type of Coverage: Medical ________ Dental ________ Drug ________Vision ________ Hearing ________
(D) Please list the names of those covered under the other health plan:
1) ______________________ 2) _______________________ 3) _______________________ 4) _________________________
5) ______________________ 6) _______________________ 7) _______________________ 8) _________________________
(E) If there is a court decree allocating responsibility for any dependent’s coverage, please attach a copy of it and provide the
Name of custodial parent: __________________________________________________________________________________
Name(s) of the dependent(s) covered: ________________________________________________________________________
Name of the parent who has medical responsibility under the terms of the court decree: _________________________________
SECTION 2 – MEDICARE INFORMATION
If Medicare covers you, your spouse or any dependent(s), please refer to your Medicare card and complete the section below.
Name of Medicare Cardholder
Medicare
Effective Dates for Each PART
Medicare Entitlement
Reason (Circle One)
Claim Number
A: __/__/__ B: __/__/__ D: __/__/__
Age
Disability
*ESRD
A: __/__/__ B: __/__/__ D: __/__/__
Age
Disability
*ESRD
A: __/__/__ B: __/__/__ D: __/__/__
Age
Disability
*ESRD
*If kidney or renal failure is the primary reason for Medicare, please provide date of first dialysis treatment: ___ / ___/ ___ and
transplant date(s), if applicable: ___ /___ / ___
___ /___ / ___
___ /___ / ___
Are you or your spouse actively working? (If YES, please complete the employment information.)
You:
NO___ YES___ Full-Time___ Part-Time___ Employer___________________________ Phone # (___)___________
Spouse:
NO___ YES___ Full-Time___ Part-Time___ Employer___________________________ Phone # (___)___________
If you or your spouse are not actively working, have either of you retired? (If YES, please complete the retirement and
former employer information.)
You:
NO___ YES___ Retirement Date___/___/___ Employer____________________________ Phone # (___)___________
Spouse: NO___ YES___ Retirement Date___/___/___ Employer____________________________ Phone # (___)___________
SECTION 3 - CERTIFICATION
I certify that the above information is true and correct to the best of my knowledge:
Policyholder’s Signature:____________________________________ Daytime Phone #(____)_____________Date:___/___/____
If you have any questions or require assistance with completing this form,
please call the Member Services number printed on the back of your Anthem member Identification card.
Anthem Blue Cross and Blue Shield • COB Department • PO Box 27401 • Richmond, VA 23279-7401
• Phone: 1 (800) 533-1120 •
Revised 05/2009
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