Reimbursement Claim Form - Humana
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2Humana Health Plans of Puerto Rico, Inc.
___HMO ___POS ___ Other
383 FD Roosevelt Ave.
Humana Insurance of Puerto Rico, Inc.
San Juan PR 00918-2131
___PPO
REIMBURSEMENT CLAIM FORM
1.
Contract or MPI Number: _________________
2.
Group Number:
_________________
3.
Patient’s Name: ___________________________________ subscriber___ spouse ___ dependent ___
4.
Postal Address:
If you wish to notify change of address other than the one in our records please
add here:
________________________________________________________________________________________
________________________________________________________________________________________
5.
Home Phone No.: __ __ __ - __ __ __ - __ __ __ __
6.
Work Phone No.: __ __ __ - __ __ __ - __ __ __ __ Ext. ______
7.
Name of provider of services: ______________________________________________________________
(If the Physician is part of a Group, include the name of the Physician)
8.
Provider’s specialty: ________________________________ Phone No. : __ __ __ - __ __ __ - __ __ __ __
9.
Date of ser vice: (Month) __
__ (Day) __ __ (Year)__ __ __ __
10. Condition or diagnosis: ______________________________
CPT Code: _________________
__
__
11.
Any other health plan?
No
Yes
– Company: _________________ Policy / Contract No.: _____________
__
__
12.
Is this service related to an accident?
Please answer the questions:
No
Yes –
Where? ___________________ When? ___________________ How? _____________________________
13. Services Provided
Charges
Services Provided
Charges
Office Visit &/or Consultation __________
Laboratory
__________
Radiology
__________
Surgery
__________
Anesthesia
__________
Pharmacy
__________
Procedures
__________
Durable Medical Equip.
__________
Hospital Services
__________
Mental Health
__________
Emergency Room Services
__________
Other
__________
__
__
14. Did you contact Humana before service was rendered?
No
Yes, with whom? ________________
15. Please explain why you had to pay for the services:
_______________________________________________________________________________________
_______________________________________________________________________________________
16. I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT.
_______________________________
________________________________
_______________
Name
Signature
Date
Reimbursement Claim Form-062013
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