Midtown Health Plan Submission Form

Midtown Health Plan Submission Form
Welcome to the Midtown Healthcare Submission form. Please select the type of medical spending you will be using and follow the form instructions. Reminder, as of 1/1/25:
- Bills from incidents under $1,250 (before discounts) are reimbursed from your HRA.
- Bills over $1,250 (before discounts) are submitted to CHM. Personal responsibility amounts must be met before sharing.
Please email Rachel at rdespres@midtowncolumbia.com with any questions.
Name*

First NameLast Name
Email
example@example.com
What would you like to do?*
How many people are you adding?
New Member #1: Who are you adding?*
New member name:*
(first name, middle initial, and last name. ex. Jane H. Doe):
New member DOB:*

MonthDayYear
Date
New member SSN:*
New member gender:*
New member membership start date:*

MonthDayYear
For newborn dependents, select date of birth.
Is the new member Medicare or Medicaid eligible?*

NoIs eligible for Medicare, but is not currently enrolledHas Medicare AHas Medicare BHas MedicaidOther
Does this member have any pre-existing conditions? If so, which pre-existing conditions does this member have? Please select all that apply.*

This member does not have any pre-existing conditions.Acid RefluxAcneAllergiesArthritisAsthmaBack painDiabetesEczema/PsoriasisEndometriosisHigh blood pressure/hypertensionHigh cholesterolHypothyroidismHyperthyroidismMigrainesPCOSSleep ApneaAutoimmune disorders - Addison DiseaseAutoimmune disorders - Celiac DiseaseAutoimmune disorders - FibromyalgiaAutoimmune disorders - Graves diseaseAutoimmune disorders - HashimotoAutoimmune disorders - LupusAutoimmune disorders - Rheumatoid arthritisCancer - BladderCancer - BreastCancer - ColonCancer - EndometrialCancer - KidneyCancer - LeukemiaCancer - LungCancer - Non-Hodgkin's LymphomaCancer - PancreaticCancer - ProstateCancer - ThyroidHeart - ArrhythmiaHeart - Heart attackHeart - Heart failureHeart - Heart murmurHormonal imbalance - Low testosteroneJoint pain - BackJoint pain - HipJoint pain - KneeJoint pain - ShoulderSkin cancer - Basal cell carcinomaSkin cancer - MelanomaSkin cancer - Squamous cell carcinomaOther
For each pre-existing condition selected above, please list the date the condition started.*
Ex. Hyperthyroidism - started 8/1/2012
New Member #2: Who are you adding?*
New member name:*
(first name, middle initial, and last name. ex. Jane H. Doe):
New member DOB:*

MonthDayYear
Date
New member SSN:*
New member gender:*
New member membership start date:*

MonthDayYear
For newborn dependents, select date of birth.
Is the new member Medicare or Medicaid eligible?*

NoIs eligible for Medicare, but is not currently enrolledHas Medicare AHas Medicare BHas MedicaidOther
Does this member have any pre-existing conditions? If so, which pre-existing conditions does this member have? Please select all that apply.*

This member does not have any pre-existing conditions.Acid RefluxAcneAllergiesArthritisAsthmaBack painDiabetesEczema/PsoriasisEndometriosisHigh blood pressure/hypertensionHigh cholesterolHypothyroidismHyperthyroidismMigrainesPCOSSleep ApneaAutoimmune disorders - Addison DiseaseAutoimmune disorders - Celiac DiseaseAutoimmune disorders - FibromyalgiaAutoimmune disorders - Graves diseaseAutoimmune disorders - HashimotoAutoimmune disorders - LupusAutoimmune disorders - Rheumatoid arthritisCancer - BladderCancer - BreastCancer - ColonCancer - EndometrialCancer - KidneyCancer - LeukemiaCancer - LungCancer - Non-Hodgkin's LymphomaCancer - PancreaticCancer - ProstateCancer - ThyroidHeart - ArrhythmiaHeart - Heart attackHeart - Heart failureHeart - Heart murmurHormonal imbalance - Low testosteroneJoint pain - BackJoint pain - HipJoint pain - KneeJoint pain - ShoulderSkin cancer - Basal cell carcinomaSkin cancer - MelanomaSkin cancer - Squamous cell carcinomaOther
For each pre-existing condition selected above, please list the date the condition started.*
Ex. Hyperthyroidism - started 8/1/2012
New Member #3: Who are you adding?*
New member name:*
(first name, middle initial, and last name. ex. Jane H. Doe):
New member DOB:*

MonthDayYear
Date
New member SSN:*
New member gender:*
New member membership start date:*

MonthDayYear
For newborn dependents, select date of birth.
Is the new member Medicare or Medicaid eligible?*

NoIs eligible for Medicare, but is not currently enrolledHas Medicare AHas Medicare BHas MedicaidOther
Does this member have any pre-existing conditions? If so, which pre-existing conditions does this member have? Please select all that apply.*

This member does not have any pre-existing conditions.Acid RefluxAcneAllergiesArthritisAsthmaBack painDiabetesEczema/PsoriasisEndometriosisHigh blood pressure/hypertensionHigh cholesterolHypothyroidismHyperthyroidismMigrainesPCOSSleep ApneaAutoimmune disorders - Addison DiseaseAutoimmune disorders - Celiac DiseaseAutoimmune disorders - FibromyalgiaAutoimmune disorders - Graves diseaseAutoimmune disorders - HashimotoAutoimmune disorders - LupusAutoimmune disorders - Rheumatoid arthritisCancer - BladderCancer - BreastCancer - ColonCancer - EndometrialCancer - KidneyCancer - LeukemiaCancer - LungCancer - Non-Hodgkin's LymphomaCancer - PancreaticCancer - ProstateCancer - ThyroidHeart - ArrhythmiaHeart - Heart attackHeart - Heart failureHeart - Heart murmurHormonal imbalance - Low testosteroneJoint pain - BackJoint pain - HipJoint pain - KneeJoint pain - ShoulderSkin cancer - Basal cell carcinomaSkin cancer - MelanomaSkin cancer - Squamous cell carcinomaOther
For each pre-existing condition selected above, please list the date the condition started.*
Ex. Hyperthyroidism - started 8/1/2012
New Member #4: Who are you adding?*
New member name:*
(first name, middle initial, and last name. ex. Jane H. Doe):
New member DOB:*

MonthDayYear
Date
New member SSN:*
New member gender:*
New member membership start date:*

MonthDayYear
For newborn dependents, select date of birth.
Is the new member Medicare or Medicaid eligible?*

NoIs eligible for Medicare, but is not currently enrolledHas Medicare AHas Medicare BHas MedicaidOther
Does this member have any pre-existing conditions? If so, which pre-existing conditions does this member have? Please select all that apply.*

This member does not have any pre-existing conditions.Acid RefluxAcneAllergiesArthritisAsthmaBack painDiabetesEczema/PsoriasisEndometriosisHigh blood pressure/hypertensionHigh cholesterolHypothyroidismHyperthyroidismMigrainesPCOSSleep ApneaAutoimmune disorders - Addison DiseaseAutoimmune disorders - Celiac DiseaseAutoimmune disorders - FibromyalgiaAutoimmune disorders - Graves diseaseAutoimmune disorders - HashimotoAutoimmune disorders - LupusAutoimmune disorders - Rheumatoid arthritisCancer - BladderCancer - BreastCancer - ColonCancer - EndometrialCancer - KidneyCancer - LeukemiaCancer - LungCancer - Non-Hodgkin's LymphomaCancer - PancreaticCancer - ProstateCancer - ThyroidHeart - ArrhythmiaHeart - Heart attackHeart - Heart failureHeart - Heart murmurHormonal imbalance - Low testosteroneJoint pain - BackJoint pain - HipJoint pain - KneeJoint pain - ShoulderSkin cancer - Basal cell carcinomaSkin cancer - MelanomaSkin cancer - Squamous cell carcinomaOther
For each pre-existing condition selected above, please list the date the condition started.*
Ex. Hyperthyroidism - started 8/1/2012
New Member #5: Who are you adding?*
New member name:*
(first name, middle initial, and last name. ex. Jane H. Doe):
New member DOB:*

MonthDayYear
Date
New member SSN:*
New member gender:*
New member membership start date:*

MonthDayYear
For newborn dependents, select date of birth.
Is the new member Medicare or Medicaid eligible?*

NoIs eligible for Medicare, but is not currently enrolledHas Medicare AHas Medicare BHas MedicaidOther
Does this member have any pre-existing conditions? If so, which pre-existing conditions does this member have? Please select all that apply.*

This member does not have any pre-existing conditions.Acid RefluxAcneAllergiesArthritisAsthmaBack painDiabetesEczema/PsoriasisEndometriosisHigh blood pressure/hypertensionHigh cholesterolHypothyroidismHyperthyroidismMigrainesPCOSSleep ApneaAutoimmune disorders - Addison DiseaseAutoimmune disorders - Celiac DiseaseAutoimmune disorders - FibromyalgiaAutoimmune disorders - Graves diseaseAutoimmune disorders - HashimotoAutoimmune disorders - LupusAutoimmune disorders - Rheumatoid arthritisCancer - BladderCancer - BreastCancer - ColonCancer - EndometrialCancer - KidneyCancer - LeukemiaCancer - LungCancer - Non-Hodgkin's LymphomaCancer - PancreaticCancer - ProstateCancer - ThyroidHeart - ArrhythmiaHeart - Heart attackHeart - Heart failureHeart - Heart murmurHormonal imbalance - Low testosteroneJoint pain - BackJoint pain - HipJoint pain - KneeJoint pain - ShoulderSkin cancer - Basal cell carcinomaSkin cancer - MelanomaSkin cancer - Squamous cell carcinomaOther
For each pre-existing condition selected above, please list the date the condition started.*
Ex. Hyperthyroidism - started 8/1/2012
What type of medical spending are you submitting?*
Would you like to be advanced the total cost of this CHM need while you wait for reimbursement?*
I understand that once CHM reimburses me, I will need to return any advanced money to Midtown. I understand that if for any reason CHM does not share a need for which I have been advanced, the total amount will instead be deducted from my HRA balance. If I do not have enough funds remaining in my HRA to cover this amount, I understand that I will instead go into my yearly Out-of-Pocket amount and may need to return some or all of my advanced amount to Midtown.*

Yes, I understand.
I understand that in order for my medical bill to be reimbursed from my HRA or CHM, I must provide enough information about the medical need in order for the HRA administrator to make a determination on eligibility. I understand that simple descriptions like "This is a prescription" or "This is a visit" are not sufficient. I understand that specific information about the illness or accident is needed, such as "This is a prescription for my child's sinus infection" or "This is a visit for a back injury related to my accident last fall." I understand that if I don't give enough information, my bills may not be reimbursed or my CHM reimbursement may be delayed.*

Yes, I understand.
Name of Person for Medical Incident*

First NameLast Name
Date of Medical Service*

MonthDayYear
Date
Date Symptoms Began*

MonthDayYear
Date
What were the patient's symptoms? If the incident was an accident, please describe the location and circumstances. *
What happened? Where did it happen? When did it happen?
What was your provider's diagnosis? What treatment did they prescribe?*
Do you have any further care scheduled related to this medical incident?*
If yes, please provide the date and description of care related to the medical incident.
Did you have signs, symptoms, or treatment of this condition before joining CHM?*
Did you request discounts from your medical provider? (Remember to ask that self-pay discounts be applied.)*
Did you ask for financial aid from your medical provider?*
Did you ask to be set up on a payment agreement with your medical provider?*
If yes, how much per month did you agree to pay?
How many itemized medical bills do you need to submit for this medical incident?*
Please attach a copy of your first itemized medical bill here.*

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What is the total amount of your first bill before discounts are applied?*
What is the total amount of your first bill after discounts are applied?*
Please attach a copy of your second itemized medical bill here.*

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What is the total amount of your second bill before discounts are applied?*
What is the total amount of your second bill after discounts are applied?*
Please attach a copy of your third itemized medical bill here.*

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What is the total amount of your third bill before discounts are applied?*
What is the total amount of your third bill after discounts are applied?*
Please attach a copy of your fourth itemized medical bill here.*

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What is the total amount of your fourth bill before discounts are applied?*
What is the total amount of your fourth bill after discounts are applied?*
Please attach a copy of your fifth itemized medical bill here.*

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What is the total amount of your fifth bill before discounts are applied?*
What is the total amount of your fifth bill after discounts are applied?*
Please attach a copy of your sixth itemized medical bill here.*

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What is the total amount of your sixth bill before discounts are applied?*
What is the total amount of your sixth bill after discounts are applied?*
Please attach a copy of your seventh itemized medical bill here.*

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What is the total amount of your seventh bill before discounts are applied?*
What is the total amount of your seventh bill after discounts are applied?*
Please attach a copy of your eighth itemized medical bill here.*

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What is the total amount of your eighth bill before discounts are applied?*
What is the total amount of your eighth bill after discounts are applied?*
Please attach a copy of your ninth itemized medical bill here.*

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What is the total amount of your ninth bill before discounts are applied?*
What is the total amount of your ninth bill after discounts are applied?*
Please attach a copy of your tenth itemized medical bill here.*

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What is the total amount of your tenth bill before discounts are applied?*
What is the total amount of your tenth bill after discounts are applied?*
Any additional comments or questions
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