Costco Flu Shot Program Form (Page 2 of 2) in pdf

Costco Flu Shot Program Form Page 2

flu shoT CliniC

insuranCe informaTion

If paying for your employees’ flu shots is not an option, the flu shots may be billed to their insurance. We will need their

insurance card information to verify that the insurance company will cover the cost of the flu shot.

Please complete the information below if you wish to bill the cost of the Flu Shot Clinic to your insurance company.

Company Name: ______________________________________________________________________________________

Employee Name: ______________________________________________ Date of Birth: ___________________________

Primary Insurance Holder

: ________________________________________________________

(if different from Employee Name)

Address: _____________________________________________________________________________________________

STREET

_____________________________________________________________________________________________________

CITY

STATE

ZIP

Name of Insurance Company: ___________________________________________________________________________

Identification Number: _____________________________________

Group Number: ______________________________

Rx Bin Number:

___________________________________________________________________________________________________________________

ABC

Insurance

Example:

ID#: 12345678

01 John Doe

02 Jane Doe

Group: 5454

SubmIt Rx claImS oNlINe to abc Insurance

Rx bin: 015342

Questions?

Call or email: _________________________________________________________________________________

CoSTCo MARkETING MANAGER

PHoNE

Please fax completed form to:

__________________________________________________________________________

13AB0906 6/13

Costco Flu Shot Program Form Page 2