Coordination Of Benefits Questionnaire Template - Blue Cross Blue Shield Of Michigan
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1COORDINATION OF BENEFITS QUESTIONNAIRE
If you, your spouse or any of your covered dependents do not have any other health insurance, call our automated
response number at 1-866-263-9494. If there is other health coverage, you can update your coordination of benefits
information at or complete this form.
SECTION 1
YOUR BCBSM INFORMATION
BCBSM enrollee name (as found on your ID card)
BCBSM enrollee ID / contract number
Are you, your spouse or any of your dependents covered by another health plan other than Medicare?
NO –
YES –
Please skip the rest of the questions, sign the
Please complete the entire form, sign the
bottom of this form and return.
bottom of this form and return.
SECTION 2
OTHER HEALTH COVERAGE INFORMATION
Please provide the following information about the policyholder of the other health coverage. Attach additional pages if needed.
Name of policyholder of other coverage
Relationship to you
Employer
Birth date
Insurance company name
Insurance company city
State
Phone number
Enrollee ID / policy number
Group number
Effective date
Cancellation date (if applicable)
Is this a retiree contract?
Yes
No
Type of coverage
Type of plan:
Medical
Prescription drugs
Is this a COBRA contract?
Yes
No
(check all that apply)
Single
Family
Is policy holder laid-off?
Yes
No
Dental
Medicare Advantage
Who is covered by this other plan? Include yourself if applicable.
Name (first and last)
Relationship to you
Name (first and last)
Relationship to you
1.
4.
2.
5.
3.
6.
SECTION 3
SPECIAL SITUATIONS
Fill out this section only if your children have health care coverage in addition to the above because of divorce, separation or court
order.
(attach a copy of the sections that apply to health care
Is there a court order that determines responsibility for health
No
Yes
responsibility and/or custody arrangements)
care coverage or custody?
Name of person responsible for child’s health care coverage
Employer
Birth date
Insurance company name
Insurance company city
State
Phone number
Enrollee ID / policy number
Group number
Effective date
Cancellation date (if applicable)
Which children are covered by this insurance?
Child’s name (first and last)
Who has custody
Child’s name (first and last)
Who has custody
1.
4.
2.
5.
3.
6.
Subscriber’s signature:
Date:
Return completed forms to:
COB Membership — 610J
Blue Cross Blue Shield of Michigan
OR
Fax: 866-581-3946
600 E. Lafayette Blvd.
Detroit, MI 48226-9942
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