Other Insurance Form

1
In order to properly evaluate claims for the patient and your spouse/dependents, the following information is required and will be requested annually.
2
Member ID (located on your ID card)* This field is required.
3
Email
example@example.com
4
Name of other Policy Holder* This field is required.
First Name
Last Name
5
Policy Holder's date of birth* This field is required.
Date
Month
Day
Year
6
Do you, your spouse or any of your dependents currently have or in the past year have had other insurance coverage besides the coverage you have administered through Insight Benefit Administrators?* This field is required.
Yes
No
7
Name of Company the other Policy Holder is/was employed with
8
Name and Phone Number of the other Insurance Carrier
9
Check other coverage that applies:
Medical
Dental
Vision
10
Effective date of other coverage
Date
Month
Day
Year
11
End date of other coverage
Date
Month
Day
Year
12
List all who are/were covered under the other insurance and their relationship to you.
13
Are any of your dependents/spouse disabled?
Yes
No
14
If yes, for what condition
15
The statements made above are true and accurate to the best of my knowledge. I understand that federal laws provide for criminal penalties for submitting knowingly or making false, fictitious or fraudulent statement or claim in any manner. Because personal information is requested from you, we are required by HIPAA to notify you of the following: This information is requested under the authority of Chapter 55, Title 10, United States Code, Section 1076A. The information is requested to update enrollment records in order to process claims. Routinely, this information will be used to determine eligibility for benefits and to review and process claims.
16
Name of Employee* This field is required.
First Name
Last Name
17
Tags
Todo
In Progress
Done
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