Health Insurance Fact Request
Download a blank fillable Health Insurance Fact Request in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Health Insurance Fact Request with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Reset Form
Ohio Department of Medicaid
HEALTH INSURANCE FACT REQUEST
Complete this form to request an update of the recipient’s private health insurance or Medicare information in the Medicaid claims payment system.
Providers are expected to verify the recipient’s health care coverage.
Please select which health insurance information to update:
Private health insurance
Medicare
Provider Information:
Provider #
Provider Name
Address
City
State
Zip Code
Contact Person
Phone Number
Recipient Information:
Patient(s) Name
Medicaid Billing #
Patient’s Phone Number
Name of Insurance
Address
City
State
Zip Code
Insurance Carrier Phone Number
Policy Holder Name
Policy # or Medicare #
Policy Group Number
Policy Holder Social Security Number (SSN)
Policy Holder Phone Number
Policy Holder’s Employer Name
Employer Address
Employer City
Employer State
Employer Zip Code
Employer Phone Number
st
If payment has been received from health insurance other than Medicaid or Medicare, please note 1
payment date:
/
/
Date health insurance terminated per attached documents:
/
/
Additional Comments
Return original to:
Coordination of Benefits Section
Cost Avoidance Unit
P.O. Box 182410
Columbus, Ohio 43218-2410
If you have questions contact the Coordination of Benefits Section at (614) 752-5768. The FAX number is (614) 728-0757.
ODM 06614 (7/2014)
Formerly JFS 06614 (Rev. 10/2010)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal