Member Reimbursement Medical Claim Form
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21199SEIU Benefit Funds
330 West 42nd Street • New York, NY 10036-6977 • Tel: (646) 473-7160 • Outside NYC area codes: (800) 575-7771 •
MEMBER REIMBURSEMENT MEDICAL CLAIM FORM
Please print clearly in blue or black ink.
PART A: MEMBER INFORMATION
___________________________________________________________________________________________________________________________________________
Member’s full name
Member ID #
___________________________________________________________________________________________________________________________________________
Address
City
State
Zip code
___________________________________________________________________________________________________________________________ Sex: M
F
Primary telephone
Date of birth
___________________________________________________________________________________________________________________________________________
Name of employer
Date of hire
Current marital status:
Single
Married
Divorced
Widowed
Legally separated
Do you or your dependent child(ren) or spouse have other health insurance coverage?
No
Yes
__________________________________________________________________________
Relationship to member:
Self
Spouse
Dependent child
If “yes,” name of person covered
___________________________________________________________________________________________________________________________________________
Name of insurance plan
Policy/Group number
___________________________________________________________________________________________________________________________________________
Insurance plan telephone
Effective date of coverage
PART B: PATIENT INFORMATION
___________________________________________________________________________________________________________________________ Sex: M
F
Patient’s full name
Patient’s date of birth
Patient’s relationship to subscriber:
Self
Spouse
Dependent child
Other: _____________________________________________________________
(Please specify)
Is patient a dependent who is age 19 or older? No
Yes
If “yes,” Part C: Young Adult Information must be completed (see below).
Was injury or condition related to:
A. Patient’s employment:
No
Yes
B. Accident:
Auto
Other: _____________________________________________________________
(Please specify)
___________________________________________________
Has legal action been taken, or will it be?
No
Yes
If accident, give date accident occurred
___________________________________________________________________________________________________________________________________________
If “yes,” give lawyer’s full name
Lawyer’s telephone number
___________________________________________________________________________________________________________________________________________
Address
City
State
Zip code
I authorize the release to or by the Funds of any medical information necessary to process this claim.
X
________________________________________________________________________________________________________________________________________
Patient’s signature
Date
I authorize payment of medical benefits to the undersigned physician or supplier for the services described in Part D.
X
________________________________________________________________________________________________________________________________________
Member’s signature
Date
PART C: YOUNG ADULT INFORMATION
– This part must be completed each time a claim is submitted for a dependent child age 19 to 26.
___________________________________________________________________________________________________________________________________________
Dependent’s full name
Dependent’s Social Security #
_____________________________________________________
Is dependent employed?
No
Yes
If “yes,” give name and address of employer:
Dependent’s date of birth
_______________________________________________________________________________________________________________
Full time
Part time
Name of dependent’s employer
___________________________________________________________________________________________________________________________________________
Address
City
State
Zip code
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