Coordination Of Benefits Form
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2Coordination of Benefits Form
Please submit this form with all supporting documentation to Oxford’s Coordination of Benefits Department at:
Mailing Address: P.O. Box 7071, Bridgeport, CT 06601-9630 • 800-767-3840
SUBSCRIBER INFORMATION (Please Print Clearly Or Type)
Oxford Subscriber Name:
Oxford ID Number:
Employment Information
(Please check the appropriate boxes)
Actively at Work:
Yes
No
Total number of employees at company is:
1-19
20-99
100+
/
/
MM DD YY
Retired:
Yes
No
Date of Retirement:
Spouse’s Social Security Number:
/
/
MM DD YY
Spouse’s Name:
Spouse’s Date of Birth:
Spouse’s Current Employer/Company Name:
Spouse's Employer Address/Phone Number:
COVERAGE INFORMATION
Please note: If you, your spouse or dependent(s) have:
• Other coverage, please complete Part A1, then sign and date the form.
• No other coverage, please complete Part A2, then sign and date the form.
• Been divorced/legally separated/single parent, please complete Part B in addition to Part A, then sign and date the form.
• Medicare coverage, please complete Part C, then sign and date the form.
PART A
1. Other Coverage (list each separately)
Carrier Name:
Carrier Address:
Telephone #:
Subscriber’s Name:
Policy #:
Subscriber’s SS #:
/
/
/
/
MM DD YY
MM DD YY
Policy Effective Dates: Start
End
Covered Dependents:
Coverage Type:
(Check applicable)
Hospital
Major Medical
Prescription
Dental
Retiree
COBRA
Other
Carrier Name:
Carrier Address:
Telephone #:
Subscriber’s Name:
Policy #:
Subscriber’s SS #:
/
/
/
/
MM DD YY
MM DD YY
Policy Effective Dates: Start
End
Covered Dependents:
Coverage Type:
(Check applicable)
Hospital
Major Medical
Prescription
Dental
Retiree
COBRA
Other
If the other coverage is no longer in effect, you must enclose documentation from the former carrier indicating the date the
policy was terminated.
2. No Other Coverage
If your spouse does not have other health coverage, please indicate the reason:
Not married
/
/
Benefits not offered
Unemployed
Self-employed
Waived, as of:
/
/
Part-time employee (not eligible for benefits)
Waiting period, eligible for coverage on:
Other, please explain:
Please turn over
MS-00-093
2516 2/01 Rev 2
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Parent category: Business