Download Coordination of Benefits Questionnaire

Coordination of Benefits Questionnaire
Member Name:_____________________________________________ Date of Birth: _____/_____/_____
00000000000
CareConnect ID:
Telephone Number: (______)__________________
Does the member or do the member’s covered spouse, domestic partner, or dependent(s) have
additional/other health insurance coverage (including for example, other health, Medicare, or
mandatory automobile “no fault” or “fault” type coverage)?
¨
No, there is not any other insurance for this patient or their dependents.
If you answered No, STOP here the questionnaire is complete.
¨
Yes, there is other insurance.
If you answered Yes, please complete the following with respect to the other coverage referenced above:
Type(s) of additional/other health insurance:
¨ Other Health or Medical (Please specify: _____________________________________________)
¨ Dental ¨ Vision ¨ Major Medical ¨ Prescription ¨ Medicare ¨ Automobile
If you selected Medicare as your additional/other health insurance coverage, please skip ahead
to Section 3. All other health insurance types please continue to Section 1.
Section 1: Additional/Other Health Insurance Information
a. List all individuals covered: ________________________________________________________
______________________________________________________________________________
b. Name of Subscriber: _____________________________________________________________
c. Other Insurance Carrier’s Name: ____________________________________________________
d. Policy Number: ______________________________________Effective Date: _____/_____/_____
e. Employer's Name & Phone Number: _________________________________________________
f.
Employment Status of Policyholder:
g. Does the above contract provide:
¨ Active
¨ Retired
¨ Single Coverage
¨ Family Coverage
h. If this is a family contract, please provide:
Subscribers Birthdate: _____/_____/_____
CareConnect Insurance Company, Inc.
Continued on next page
Covered Spouse/Domestic Partner’s Birthdate: _____/_____/_____
Birthdates of each covered Dependent: _____/_____/_____
_____/_____/____
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
Section 2: Additional/Other Health Insurance Dependent Information
Only to be completed if there are dependent children covered under the other policy and the parents
are divorced or legally separated). If this section does not apply to you this questionnaire is complete.
Please mail it back in the enclosed postage paid envelope.
Are you the parent with custody?
¨ Yes
¨ No
¨ Joint
Has a court order been issued stating that the parent with custody is responsible for the child's health care
expense?
¨ Yes
¨ No
If you answered Yes to both questions above, STOP HERE! The questionnaire is completed.
If you answered No to either of the questions above, please continue with the questions in this section.
Please complete the following for the parent with custody that is not the subscriber:
a. Name of parent with custody:_________________________________________________________
b. Policyholder’s Name: _______________________________________________________________
c. Insurance Company Name: __________________________________________________________
d. Policy Number: ________________________________________Effective Date: _____/_____/_____
e. Does the above contract provide:
f.
¨ Single Coverage
¨ Family Coverage
Birthdate of parent without custody: _____/_____/_____
g. Type of insurance:
¨ Health ¨ Dental ¨ Vision ¨ Major Medical ¨ Prescription
Please complete the following for spouse of the parent with custody of child:
h. Policyholder’s Name: ______________________________________________________________
i.
Insurance Company Name: _________________________________________________________
j.
Policy Number: ______________________________________Effective Date: _____/_____/_____
CareConnect Insurance Company, Inc.
Continued on next page
k. Does the above contract provide:
l.
¨ Single Coverage
¨ Family Coverage
Birthdate of spouse of parent with custody: _____/_____/_____
m. Type of insurance: ¨ Health
¨ Dental ¨ Vision ¨ Major Medical ¨ Prescription
Section 3: Medicare Eligibility
a. List all individuals covered: ________________________________________________________
______________________________________________________________________________
b. Name of Subscriber: _____________________________________________________________
c. Other Insurance Carrier’s Name: ____________________________________________________
d. Policy Number: ___________________________________Effective Date: _____/_____/_____
e. Is the member entitled to or eligible for benefits under Medicare Part A (hospital insurance)?
¨ Yes
f.
¨ No
Part A Effective Date: _____/_____/______
Is the member entitled to benefits under Medicare Part B (medical insurance)?
¨ Yes
¨ No
Part B Effective Date: _____/_____/______
g. Is the member entitled to benefits under Medicare Part D (medical insurance)?
¨ Yes
¨ No
Part D Effective Date: _____/_____/______
If Yes, what is the Medicare number from the Medicare ID Card? _________________________
h. Employment status of Medicare enrollee:
¨
i.
Active
¨ Retired
- - Retirement Date: _____/_____/_____
Employment status of CareConnect subscriber:
¨ Active
¨ Retired
- - Retirement Date: _____/_____/_____
Thank you for taking the time to complete this questionnaire!
Please mail it back in the enclosed postage paid envelope.
CareConnect Insurance Company, Inc.