Coordination Of Benefits Form Page 2
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1
2COVERAGE INFORMATION
Please Print
(Continued)
PART B
Please complete this section if you are divorced, legally separated, or a single parent, and you have dependent children covered under
this plan.
1.
Does the other biological parent of your dependent children provide health benefits?
Yes
No
MM DD YY
/
/
Name of other biological parent:
Birth date:
If yes, please provide the following information:
Name of other health plan:
Policy #:
Subscriber’s SS #:
Which children are covered?
/
/
MM DD YY
2.
Are you divorced or legally separated?
Yes
No
Date of divorce/separation:
Are you a single parent?
Yes
No
If divorced, check one of the following:
Divorce decree stipulates other parent must provide health benefits
Divorce decree stipulates joint custody
Divorce decree does not stipulate any special provisions
Other, please explain:
*A copy of the section of the court decree pertaining to health coverage or other documents must be provided to support your response.
PART C
You should complete this section if you, your spouse, and/or your dependents are eligible for Medicare. Please enclose a copy of the
Medicare ID card for each eligible member of your family.
Name of Member eligible for Medicare:
Name of Member eligible for Medicare:
Effective Dates of Medicare:
Effective Dates of Medicare:
/
/
/
/
MM DD YY
MM DD YY
MM DD YY
/
/
MM DD YY
/
/
Part A:
Part B:
Part A:
Part B:
Reason for Medicare coverage
Reason for Medicare coverage
(please check one):
(please check one):
Age 65 or older
Age 65 or older
End Stage Renal Disease (ESRD)
End Stage Renal Disease (ESRD)
MM DD YY
/
/
/
/
MM DD YY
Date Dialysis Treatment Began:
Date Dialysis Treatment Began:
Disability, due to:
Disability, due to:
SUBSCRIBER SIGNATURE
I certify that the above information is correct and understand that I am obligated to provide this information to Oxford in accordance
with the Certificate of Coverage. Failure to provide complete and accurate information may result in a delay in the payment of benefits.
Print Your Name:
Signature:
Date:
Oxford ID Number:
2516 2/01 Rev 2
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