• Coordination of Benefits

    Coordination of Benefits

    In order to accurately process your benefits, we must keep our records up to date. To avoid any delay in the processing of claims, please provide us with the following information.
  • Date*
     / /
  • Are you, your spouse/partner and/or dependent(s) enrolled in any other health coverage?*
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  • Do you need to add other family members enrolled in health coverage?*
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  • Do you need to add other family members enrolled in health coverage?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Do you need to add other family members enrolled in health coverage?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Do you need to add other family members enrolled in health coverage?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Do you need to add other family members enrolled in health coverage?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Do you need to add other family members enrolled in health coverage?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Other coverage includes:*
  • Date of Birth*
     / /
  • Effective Date*
     / /
  • Covered End Date (if applicable)
     / /
  • Are you or any of your dependents are enrolled on:*
  • Medicaid Effective Date
     / /
  • Part A Effective Date
     / /
  • Part B Effective Date
     / /
  • Part D Effective Date
     / /
  • Reason for Medicare entitlement:*
  • ESRD onset Date (if Applicable)
     / /
  • Do you need to add other dependents are enrolled on:*
  • Medicaid Effective Date
     / /
  • Part A Effective Date
     / /
  • Part B Effective Date
     / /
  • Part D Effective Date
     / /
  • Reason for Medicare entitlement:*
  • ESRD onset Date (if Applicable)
     / /
  • Do you need to add other dependents are enrolled on:*
  • Medicaid Effective Date
     / /
  • Part A Effective Date
     / /
  • Part B Effective Date
     / /
  • Part D Effective Date
     / /
  • Reason for Medicare entitlement:*
  • ESRD onset Date (if Applicable)
     / /
  • Do you need to add other dependents are enrolled on:*
  • Medicaid Effective Date
     / /
  • Part A Effective Date
     / /
  • Part B Effective Date
     / /
  • Part D Effective Date
     / /
  • Reason for Medicare entitlement:*
  • ESRD onset Date (if Applicable)
     / /
  • Do you need to add other dependents are enrolled on:*
  • Medicaid Effective Date
     / /
  • Part A Effective Date
     / /
  • Part B Effective Date
     / /
  • Part D Effective Date
     / /
  • Reason for Medicare entitlement:*
  • ESRD onset Date (if Applicable)
     / /
  • Do you need to add other dependents are enrolled on:*
  • Medicaid Effective Date
     / /
  • Part A Effective Date
     / /
  • Part B Effective Date
     / /
  • Part D Effective Date
     / /
  • Reason for Medicare entitlement:*
  • ESRD onset Date (if Applicable)
     / /

  • Please review your responses carefully before signing and submitting this form.

  • If you have any questions, please contact our customer service department at 877-585-8480.

     

    PO Box 450978      |      Westlake, OH 44145      |      877-585-8480

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