SAMPLE CMS/PED-I-CARE MEMBER I by hGF50a

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									                             SAMPLE CMS/PED-I-CARE MEMBER I.D. CARDS
                                                                          Revised 3/2011




                                                   Sample Medicaid Member ID Card

                                    (front)                                                                                        (back)
                                                                                             Physician or Hospital: Non-emergency            Emergency services require notification
                                  Medicaid                                                   Admissions require prior authorization.
                                                                                             Contact the MED3000 UM Department:
                                                                                                                                             to PCP including notes, labs, and other
                                                                                                                                             diagnostics within 48 hours.
                             Provider Service Network                                        (800) 492-9634.

                                                                                                                    ELIGIBILITY VERIFICATION: INFOsource
 Member Name: John Doe                                 Date of Birth: 01/01/2001                      (https://PedICare.eINFOsource.med3000.com) or call (800) 664-0146
 Member ID: 999999999                                 Effective Date: 05/01/2007                        (This card is not proof of CMS or Ped-I-Care network enrollment)
            PCP: Duval County HD – Wesconnett Health Center
                          5150-9 Timuquana Rd                                                           Provider Claims/Customer Service: (800) 664-0146
                          Jacksonville, FL 32210                                               Utilization Management – Referrals/Authorizations: (800) 492-9634
                        PCP Phone: 352-123-4567                                              Claims Address: CMS/Ped-I-Care, PO Box 10885, Pensacola, FL 32524
                                                                                                                            (All claims except Pharmacy)
           CMS Office: Jacksonville CMS Phone: (800) 523-7545
                      MEMBER SERVICES: (866) 376-2456                                                        Pharmacy: Use your Medicaid Prescription card at any
                1701 SW 16th Ave, Bldg A, Gainesville, FL 32608-1153                                                   pharmacy that accepts Medicaid.
                                                                                                             Transportation: Call TMS Management (866) 867-0729
Members must present their ID Card to each provider before receiving medical services.
         (This card is not proof of CMS or Ped-I-Care network enrollment)
                                                                               Form T19-1a                                                                                  Form T19-1b




              This card is to be used by CMS/Ped-I-Care patients for all services, except pharmacy
                                                   benefits.




                                                     Sample Title 21 Member ID Card

                                    (front)                                                                                        (back)
                             CMS Title XXI                                                   Physician or Hospital: Non-emergency
                                                                                             Admissions require prior authorization.
                                                                                                                                             Emergency services require notification
                                                                                                                                             to PCP including notes, labs, and other
                                                                                             Contact the MED3000 UM Department:              diagnostics within 48 hours.
                                                                                             (800) 492-9634.
                        Member Name: John Doe
        Date of Birth: 01/01/2001     Member ID: 999999999                                                          ELIGIBILITY VERIFICATION: INFOsource
                                                                                                      (https://PedICare.eINFOsource.med3000.com) or call (800) 664-0146
            PCP: Duval County HD – Wesconnett Health Center
                                                                                                        (This card is not proof of CMS or Ped-I-Care network enrollment)
                       PCP Phone: 352-123-4567
           CMS Office: Gainesville        CMS Phone: 800-555-5555                                       Provider Claims/Customer Service: (800) 664-0146
                                                                                               Utilization Management – Referrals/Authorizations: (800) 492-9634
                      MEMBER SERVICES: (866) 376-2456                                        Claims Address: CMS/Ped-I-Care, PO Box 10885, Pensacola, FL 32524
  Members must present their ID Card to their PCP, hospital or other provider before                                        (All claims except Pharmacy)
                         receiving any medical services.
                                                                                                                         Pharmacy Carrier #10180
ELIGIBILITY VERIFICATION: INFOsource (https://INFOsource.pensacola.med3000.com)                                          Group: CMN01 BIN: 3585
                                  or call (800) 664-0146                                                       MedImpact Pharmacy Help Desk – (800) 788-2949
           (This card is not proof of CMS or Ped-I-Care network enrollment.)
                                                                               Form T21-1a                                                                                  Form T21-1b



                                                                                                                                                                            Form T21-1b

								
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