• 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*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Are you, your spouse/partner and/or dependent(s) enrolled in any other 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
  • 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*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Effective Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Covered End Date (if applicable)
     / /
    2 digit month, 2 digit day, 4 digit year
  • Are you or any of your dependents are enrolled on:*
  • Medicaid Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part A Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part B Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part D Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Reason for Medicare entitlement:*
  • ESRD onset Date (if Applicable)
     / /
    2 digit month, 2 digit day, 4 digit year
  • Do you need to add other dependents are enrolled on:*
  • Medicaid Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part A Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part B Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part D Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Reason for Medicare entitlement:*
  • ESRD onset Date (if Applicable)
     / /
    2 digit month, 2 digit day, 4 digit year
  • Do you need to add other dependents are enrolled on:*
  • Medicaid Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part A Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part B Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part D Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Reason for Medicare entitlement:*
  • ESRD onset Date (if Applicable)
     / /
    2 digit month, 2 digit day, 4 digit year
  • Do you need to add other dependents are enrolled on:*
  • Medicaid Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part A Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part B Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part D Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Reason for Medicare entitlement:*
  • ESRD onset Date (if Applicable)
     / /
    2 digit month, 2 digit day, 4 digit year
  • Do you need to add other dependents are enrolled on:*
  • Medicaid Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part A Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part B Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part D Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Reason for Medicare entitlement:*
  • ESRD onset Date (if Applicable)
     / /
    2 digit month, 2 digit day, 4 digit year
  • Do you need to add other dependents are enrolled on:*
  • Medicaid Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part A Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part B Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part D Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Reason for Medicare entitlement:*
  • ESRD onset Date (if Applicable)
     / /
    2 digit month, 2 digit day, 4 digit year

  • 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

  • Should be Empty: