Fillable Form Cl07352-3 - Care Provider Assessment printable pdf download

Claims Department

PO Box 21008

Dept 0514

Greensboro, NC 27420-1008

Phone 800-487-1485

CARE PROVIDER ASSESSMENT

•

Please answer all questions completely.

•

This form should be completed by the agency or individual that is providing care services for our Insured. If there are

multiple agencies or individuals, each provider will need to complete a separate form.

•

Please feel free to contact us at 800-487-1485 if you have any questions regarding this form or its completion.

INSURED INFORMATION

Insured’s Name: _____________________________________

Policy Number: ______________________________

Date of Birth: ________________________________________

Age: ______

SSN: __________________________

PROVIDER INFORMATION

Please Choose Type:

h Facility

h Individual Caregiver

Facility/Agency

Corporate Name: ___________________________________________________________________________________

D/B/A: ___________________________________________________________________________________________

Address: _________________________________________________________________________________________

City: _____________________________________________ State: _______ ZIP: _______________________________

Phone: ___________________________________________ Fax: ___________________________________________

Type of Facility/Agency: ______________________________________________________________________________

Please list any licenses or accreditations

_____________________________________

(Please Submit copies of any listed.):

_________________________________________________________________________________________________

Are you Medicare Certified?

h Yes

h No

If yes, is the insured bed classification Medicare Certified?

h Yes

h No

Are the patient’s expenses covered by Medicaid, workers’ compensation, employer’s liability, occupational disease, motor

vehicle no fault, and/or any governmental program coverage?

h Yes

h No

If yes, list policy or contract holder, policy or contract number

and name and address of the insurance company or administrator.

(s)

_________________________________________________________________________________________________

Medicare h Part A h Part B

(Doctor’s Plan)

INDIVIDUAL CAREGIVER

Name: ___________________________________________________________________________________________

Address: _________________________________________________________________________________________

City: _____________________________________________ State: _______ ZIP: _______________________________

Phone: ___________________________________________________________________________________________

Are you related to the insured in any way?

h Yes

h No

If Yes, what is the relationship? ________________________________________________________________________

Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.

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Form Cl07352-3 - Care Provider Assessment

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