Health Insurance Information - California Children'S Services
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1
2Department of Health Care Services
State of California—Health and Human Services Agency
CALIFORNIA CHILDREN’S SERVICES
Medical Insurance
HEALTH INSURANCE INFORMATION
Dental Insurance
Patient’s name
CCS number
County
Type of insurance plan (check one)
Major medical
Preferred Provider Organization (PPO)
Health Maintenance Organization (HMO)
1.
Name of insurance plan
Policy identification/group number
Effective date of policy
Claims office address (number, street)
City
State
ZIP code
Phone number
(
)
2.
Policy holder’s name
Social security number
Address (number, street)
City
State
ZIP code
3.
Employer of insured
Phone number
(
)
Address (number, street)
City
State
ZIP code
4.
Union name
Local number
Address (number, street)
City
State
ZIP code
DESCRIPTION OF INSURANCE BENEFITS
Child’s Professional Care (Maximum Amount)
Coverage
Extent
Child’s Hospital Care (Maximum Amount)
Yes
No
5. Office visits
$
13.
Room and board
Yes
No
6. Outpatient, x-ray, laboratory
$
$________________ per day for
___________days
7. Surgery
$
14.
Miscellaneous hospital services
$
8. Assistant surgery
$
15.
Limitations:
9. Anesthesia
$
10. Hospital visits
$
11. Other
$
12. Limitations:
16. Major medical or extended benefits
Yes
No
Yes No
Yes No
Yes No
Prescriptions
Brace repairs
Dental plan
Glasses/repair
Hearing aids
Orthodontics
Braces
Hearing aid accessories
Other:
17. Deductible $_______________ at _________% per
Calendar year
Benefit year
If benefit year, effective date ____________________________
If newborn, effective date of policy
18. Maximum benefits $_______________ per
Lifetime of policy:
Illness
Year
19. I agree to repay California Children’s Services any insurance proceeds improperly diverted by me. I acknowledge the Privacy Statement
on the back side of this form.
Signature of parent or legal guardian
Date
Report completed by
Title
Date
MC 2600 (09/07)
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Parent category: Legal