Member Reimbursement Medical Claim Form Page 2
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2My dependent child listed on previous page is 19 to 26 years of age and is my biological or adopted child.
X
________________________________________________________________________________________________________________________________________
Member’s signature
Date
X
________________________________________________________________________________________________________________________________________
Dependent’s signature
Date
PART D: PHYSICIAN OR SUPPLIER INFORMATION
– Please have physician or supplier complete all items.
_____________________________________________________
Was this an initial consultation?
No
Yes
Date of first treatment for condition
Is condition due to injury or illness arising out of patient’s employment?
No
Yes
For service related to hospitalization, give hospitalization dates: _______________________________________
______________________________________
Date admitted
Date discharged
___________________________________________________________________________________________________________________________________________
Name of hospital
___________________________________________________________________________________________________________________________________________
Address of hospital
City
State
Zip code
Will any claim for the services reported below be filed with any other insurance carrier or benefit provider?
No
Yes
_________________________________________________________________________________________________________ Preventive checkup?
No
Yes
If “yes,” please specify
Diagnosis or nature of injury or illness (if diagnosis code is other than ICD-10,* give name):
___________________________________________________________________________________________________________________________________________
1. Primary
2. Secondary
___________________________________________________________________________________________________________________________________________
3. Secondary
4. Secondary
___________________________________________________________________________________________________________________________________________
ICD-10 code
Report of Services (or attach itemized bill):
Procedure Code, if Used (if code other than
Date of Services
Place of Services †
Description of Surgical or Medical Services Rendered
Charges
CPT-4** used, give name)
† DO – Doctor’s office
IH – Inpatient hospital
NH – Nursing home
TOTAL CHARGES $ _________________
H – Patient’s home
OH – Outpatient hospital
OL – Other location
AMOUNT PAID $ _________________
*ICD-10 – International Classification of Diseases
**CPT – Current Procedural Terminology (current condition)
BALANCE DUE $ _________________
___________________________________________________________________________________________________________________________________________
Name of referring physician
Specialty
___________________________________________________________________________________________________________________________________________
Address
City
State
Zip code
___________________________________________________________________________________________________________________________________________
Telephone
Individual practitioner’s Social Security #
NPI #
X
________________________________________________________________________________________________________________________________________
Physician’s signature
Date
NOTE: If you are accepting an assignment of benefits, please supply individual practitioner’s SS# to avoid delay in payment.
PART E: CLAIM FILING INSTRUCTIONS
– Mail this claim form promptly. Follow these directions to avoid delay in payment.
• Member must complete Parts A and B of claim form.
• Complete Part C if claim is for your young adult dependent (age 19 to 26).
• Have your physician or supplier complete Part D.
• The completed form should be mailed to the Benefit Funds within 30 days of the date the services were provided.
• A separate claim form must be completed for each patient.
• If the Benefit Fund is not your primary insurer, you must attach a copy of the payment voucher from the primary insurance plan.
MAIL YOUR FORM TO:
1199SEIU BENEFIT FUNDS
PO BOX 1007
NEW YORK, NY 10108-1007
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