Nebraska Blue Cross And Blue Shield Member Questionnaire Form Page 2
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1
2Section I
Medicare Information
Enter All The
Information As
It Appears On
Your Medicare
Card For Each
Covered Person
I have Medicare because I am:
I have Medicare because I am:
65 or older
Disabled
ESRD
65 or older
Disabled
ESRD
I am:
an Active Employee
I am:
an Active Employee
Retired: Date of Retirement:
Retired: Date of Retirement:
Medicare Part D:
YES
NO
If Yes, Part D Carrier Name:
Phone No.:
Effective Date:
Section II
Other Insurance Information
Name of Policyholder (first & last)
Date of Birth
Identification Number of Other Insurance
Employer's Name
Street Address
City
State
Zip Code
Name of Other Insurance Co. Address
City
State
Zip Code
Phone Number
Type of Coverage(s):
Hospital
Physician/Medical
Prescription Drug
Dental
Effective Date:
TriCare Active Duty:
Standard Option Date:
Prime Option Date:
Retirement Date:
Type of Coverage:
Single
Family
Insured's Social Security Number:
Name of member covered by this plan
Relationship
Date of Birth
Child Custody Information:
Insurance regulations stipulate which health plan will process claims first when coordinating benefits for
dependent children whose parents are divorced, legally separated or never married. A court order could change
who is the primary insurance.
Which parent has been ordered by the court to provide insurance?
*Please enclose a copy of the court order if we have not previously received it.
Who has custody of the child(ren)?
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