Form Uhcew630249-000 - Coordination Of Benefits Form -United Healthcare
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1
2Coordination of Benefits Form
Please submit this form with all supporting documentation.
Mailing Address: Coordination of Benefits Department, P.O. Box 29143, Hot Springs, AR 71903 • 1-800-444-6222
SUBSCRIBER INFORMATION (Please Print Clearly Or Type)
Subscriber Name: ID Number:
Subscriber Employment Information
(Please check the appropriate boxes)
Actively at Work:
Yes
No
Total number of employees at company is:
1-19
20-99
100+
❑
❑
❑
❑
❑
No Date of Retirement: / /
Retired:
❑
Yes
❑
Spouse’s Employment Information
Spouse’s Name:
Spouse’s Date of Birth:
Spouse’s Current Employer/Company Name:
Spouse’s Social Security Number:
/
/
Actively at Work:
❑
Yes
❑
No Retired:
❑
Yes
❑
No Date of Retirement:
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: ___________________________________________
Policy ID: ____________________________________ Group ID: _____________________________ Telephone #: __________________________
Subscriber’s Name: ______________________________________________Subscriber’s SS #: _________________________________________
Rx BIN: ____________________________________ Rx PCN: _________________________ Rx Group: __________________________________
Policy Effective Dates: Start / / End / /
❑ Single ❑ Subscriber & Spouse ❑ Subscriber & Dependents ❑ Family
Coverage Type:
(Check applicable)
❑
Hospital
❑
Major Medical
❑
Prescription
❑
Dental
❑
Retiree
❑
COBRA
❑
Other
Carrier Name: ____________________________________________ Carrier Address: _____________________________________
Policy ID: _______________________________ Group ID: _________________________Telephone #: ______________________
Subscriber’s Name: _______________________________________ Subscriber’s SS #: ___________________________________
Rx BIN: ________________________________Rx PCN: _____________________ Rx Group: ______________________________
Policy Effective Dates: Start / /
End / /
❑ Single ❑ Subscriber & Spouse ❑ Subscriber & Dependents ❑ Family
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-06-289 Rev 1 02/2013
2516 Rev 10
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Parent category: Medical