"Coordination of Benefits Questionnaire Form - Highmark Delaware" - Delaware

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COORDINATION OF BENEFITS QUESTIONNAIRE
Your Name: __________________________________________ Highmark Member ID #: ________________
A. Within the past year, have you or any member of your family been covered by another insurance company?
q No.
q Yes. Please complete the remainder of this questionnaire.
B. Check which of the following plans provide benefits for you or any member of your family:
q Another Highmark Blue Cross Blue Shield Delaware contract?
ID #: _________________________________________
q Medicare?
HIC #: _________________ Part B effective date (mo., day, yr.): _____________________________________
q Another health insurer?
Name of other health insurance company: ________________________________________________
Name of other employer: _______________________________________________________________
Address where claims are submitted: _____________________________________________________
Name of policyholder: _________________________________________________________________
Policyholder’s date of birth (month, day, year): ______________________________________________
Policyholder’s ID #: ____________________________________________________________________
Effective date of policy (month, day, year): _________________________________________________
Cancellation date, if applicable (month, day, year): ___________________________________________
Name of person(s) covered:
Spouse :
Dependent Child(ren): ___________________________________________________________
continued on reverse side
COB-003 (R02-16)
COORDINATION OF BENEFITS QUESTIONNAIRE
Your Name: __________________________________________ Highmark Member ID #: ________________
A. Within the past year, have you or any member of your family been covered by another insurance company?
q No.
q Yes. Please complete the remainder of this questionnaire.
B. Check which of the following plans provide benefits for you or any member of your family:
q Another Highmark Blue Cross Blue Shield Delaware contract?
ID #: _________________________________________
q Medicare?
HIC #: _________________ Part B effective date (mo., day, yr.): _____________________________________
q Another health insurer?
Name of other health insurance company: ________________________________________________
Name of other employer: _______________________________________________________________
Address where claims are submitted: _____________________________________________________
Name of policyholder: _________________________________________________________________
Policyholder’s date of birth (month, day, year): ______________________________________________
Policyholder’s ID #: ____________________________________________________________________
Effective date of policy (month, day, year): _________________________________________________
Cancellation date, if applicable (month, day, year): ___________________________________________
Name of person(s) covered:
Spouse :
Dependent Child(ren): ___________________________________________________________
continued on reverse side
COB-003 (R02-16)
C. COURT ORDER / CUSTODY FOR DEPENDENT CHILDREN - Select only one if applicable
q Court Order - List individual with primary medical responsibility. (Attach Court Order)
Joint Custody - List individuals with custody responsibility.
q
q Individual Custody - List individual with whom children primarily reside.
Responsible Parent/Guardian(s)
Relation to Child
Date of Birth
Court Order/Custody
First Name
Last Name
(Ex. Mother, Father)
(mm/dd/yyyy)
Effective Date (mm/dd/yyyy)
List Children affected by Court Order/Custody.
Child’s Name
Child’s Name
Child’s Name
First
Last
First
Last
First
Last
List other insurance policy covering children affected by court Order/Custody
PolicyHolder’s Name
Policy Holder’s Sex
Policy Holder
Policy Holder
First
Last
(Ex. Male, Female)
Relationship to Child
Date of Birth (mm/dd/yyyy)
Policy Holder
Policy Holder
Policy Effective Date
Policy Type(s) of Coverage
Insurance Carrier Name
Identification Number
Date (mm/dd/yyyy)
q Medical q Drug
Your signature:
Daytime telephone number:
(
)
Please return this survey to:
Highmark Delaware
P.O. Box 1991
Wilmington, DE 19899-1991
We thank you for the time spent completing this questionnaire.
Highmark Blue Cross Blue Shield Delaware is an independent licensee of the Blue Cross and Blue Shield Association
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