Nebraska Blue Cross And Blue Shield Member Questionnaire Form printable pdf download

Nebraska Blue Cross And Blue Shield Member Questionnaire Form

Coordination of Benefits

P.O. Box 3248

(COB)

Omaha, Nebraska 68180-0001

Omaha 390-1840

Toll Free 800-462-2924

Fax 402-392-4126

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OC COQ

Dear Member:

At Blue Cross and Blue Shield of Nebraska, we're pleased to provide your health care coverage.

Your coverage contains a Coordination of Benefits (COB) provision. This provision applies when more

than one insurance plan provides you and/or your covered family members with benefits. So we can

better serve you, we need some additional information. Please complete this questionnaire and

return it to us in the enclosed reply envelope within 30 days.

As the insured member, are you:

Employed

Not employed

Retired

Date of Retirement:

Is your spouse:

Employed

Not employed

Retired

Date of Retirement:

If you, your spouse or dependent children are covered by other medical, dental or

Medicare coverage please complete the applicable section(s) on page 2 of this

form.

If no other insurance, please mark the box below.

We/I have no other medical/dental insurance or Medicare coverage. (Sign and return

this form.)

I certify the information provided is complete to the best of my knowledge.

Signature

Date

Home Phone

Work Phone

If you have any questions about this form, please call our Coordination of Benefits Department at one of the

telephone numbers shown at the top of this letter.

Thank you for your business.

Nebraska Blue Cross And Blue Shield Member Questionnaire Form