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MEDICAL CLAIM FORM

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MEDICAL CLAIM FORM Powered By Docstoc
					                                                                                                                                                                                 CLEAR FORM

                                                                               MEDICAL CLAIM FORM
                                                                                           1. COMPLETE THIS FORM                      FIRST ADMINISTRATORS, INC.
                                                                                           2. ATTACH ALL BILLS                        CLAIM DEPT.
                                                                                           3. MAIL TO ►►►►►►                          PO BOX 9900
                                                                                                                                      SIOUX CITY, IA 51102-0479
                                                                                                                                      PHONE: (800) 206-0827

MUST ALWAYS BE COMPLETED BY EMPLOYEE
EMPLOYEE NAME                                                                                                      ALTERNATE ID NUMBER                                       EMPLOYEE BIRTH DATE


HOME ADDRESS                                                                                                                                                    EMPLOYEE DAYTIME PHONE


CITY                                                                               STATE    ZIP CODE                   NAME OF EMPLOYER OR GROUP #                                             ACTIVE
                                                                                                                                                                                               COBRA
                                                                                                                                                                                               RETIREE
PATIENT NAME (IF OTHER THAN EMPLOYEE)                              MALE             PATIENT RELATIONSHIP TO EMPLOYEE             PATIENT BIRTH DATE         IS PATIENT:
                                                                                                                                                                MARRIED     SINGLE            DIVORCED
                                                                   FEMALE                                                                                       LEGALLY SEPARATED
  IS PATIENT FULL-TIME STUDENT?                # OF CREDIT HOURS              NAME OF SCHOOL
           YES          NO

ACCIDENT: PLEASE PROVIDE DETAILS
DATE OF ACCIDENT                      IS THIS A CAR ACCIDENT?                 HOW AND WHERE DID ACCIDENT HAPPEN?                                                                          TREATED
                                            YES          NO                                                                                                                             PREVIOUSLY?
                                 DID ACCIDENT HAPPEN AT WORK?                                                                                                                                  YES
                                          YES        NO                                                                                                                                        NO

ILLNESS: PLEASE PROVIDE DETAILS
DATE ILLNESS BEGAN                NATURE OF ILLNESS                                                                                                                         TREATED PREVIOUSLY?
                                                                                                                                                                                 YES      NO

IF YES, LIST: PHYSICIAN NAME                                 PHYSICIAN ADDRESS                                                                                                 DATE SEEN



IF YOU, THE PATIENT, OR SPOUSE HAS COVERAGE UNDER ANY OTHER GROUP HEALTH PLAN, HEALTH MAINTENANCE ORGANIZATION,
GOVERNMENT PLAN, OR INSURANCE POLICY WHICH ALSO PAYS FOR ANY OF THE EXPENSES OF THIS CLAIM, PROVIDE DETAILS.
NAME OF COVERED PERSON                                       RELATIONSHIP                                                                            COVERAGE:              SINGLE               FAMILY
                                                                                                                                                                            MEDICAL              DENTAL

NAME OF EMPLOYER OR GROUP, ETC. PROVIDING PLAN


NAME, ADDRESS AND PHONE NUMBER OF INSURANCE COMPANY



IS PATIENT ELIGIBLE FOR MEDICARE:              YES         NO            IF YES:      PART A        PART B        PART D                        EFFECTIVE DATE:

TYPE OF COVERAGE:            MEDICAL           DENTAL           VISION        MEDICAID         VA        IHS                   MEDICARE NUMBER:            EFFECTIVE DATE: ________________________


QUALIFYING EVENT FOR MEDICARE?                  AGE        ESRD           DISABILITY           MEDICARE DISABILITY?          YES        NO              IF YES, EFFECTIVE DATE:

                                                              EMPLOYEE, PATIENT OR PARENT MUST SIGN BELOW
PAYMENT DIRECTION:                                                                                        AUTHORIZATION TO RELASEASE INFORMATION:
I agree that payment may be made directly to the provider of medical services.         YES      NO        I hereby authorize any insurance company, payment organization, employer, hospital, or
(If payment option is not indicated, payment will be made to the medical care provider unless proof of    physician to release all information with respect to myself or any of my dependents which may
payment is attached to this claim.) I understand that I am financially responsible for any charges not    have a bearing on the benefits payable under this or any other plan providing benefits or
covered by this Benefit Plan.                                                                             services. I hereby certify the information provided is correct and true to the best of my
                                                                                                          knowledge.

X______________________________________________                          ________________________         X__________________________________________                           ____________________
    Employee, Patient or Parent (if minor)                               Date                                Employee, Patient or Parent (if minor)                              Date

ADDITIONAL INFORMATION: (use an attached sheet if needed)




                                                                              PROCEDURE FOR FILING A CLAIM
       1.    A separate claim form should be completed for each claimant on whom claims are being submitted.
                    A.     Make sure you identify your employer or group.
                    B.     If the patient is your dependent, be sure to complete all questions, including if married and if a full-time student.
                    C.     It is important to know when, how and where your accident, illness or disability began, especially if it is job or auto related.
                    D.     Questions regarding other coverage you or your dependent(s) are eligible for must be answered.
                    E.     “If payment is not to be made to provider” – you should note accordingly and sign that section.
                    F.     Patient or parent (if patient is a minor) must always sign the “Authorization to Release Information” section.
       2.    Attach all medical bills relating to claim.
                    A.     Make sure all bills identify patient.
                    B.     All bills should show date of treatment, type of service and amount of charges.
                    C.     Prescription drug bills should be on regular receipts, showing name and address of pharmacy, name of patient, date of purchase, NDC number, name of medication and charge.
       3.    If you have other coverage that is primary (including Medicare or CHAMPUS), make sure you attach a copy of their explanation of benefits and itemized bill.

				
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