CONROE ISD HOSPITAL INDEMNITY PLAN CLAIM FORM by daylah

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									                                                                                                                                                               CONROE ISD
                                                                                                                                                  HOSPITAL INDEMNITY PLAN
                                                                                                                                                               CLAIM FORM




INSTRUCTIONS                                    For Customer Service call: CBCA Administrators at (800) 631-3441
1. Answer every question within the Employee's Statement, Part A.
2. Sign the Employee's Statement, Part A, under Authorization to release Information.
3.    Attach all bills, including hospital bills, for charges that you refer to on this claim form. These bills must identify the patient's name,
      conditions treated (diagnosis), type of treatment, date each expense was incurred, and itemized charges.
4. Mail this form and the attached bills to:                     CBCA Administrators, Inc.
                                                                 PO Box 1339
                                                                 Minneapolis, MN 55440-1339



PART A - EMPLOYEE’S STATEMENT                                                                                              Employer’s Name:     Conroe ISD
                     Employee’s Name (Please Print)                                              Group Number              Your Date of Birth               Social Security Number
                                                                                            031092
                     Address: Street and No.                                                        City                                        State                            Zip Code
     FULLY

COMPLETE             Phone Number                                                        This claim is on:        Myself

      FOR            Are you covered under another Plan?                                                                Yes        No

      ALL
                     What was the sickness or injury?                                                                      On what date did it begin?       Date of first expense for this condition:
     CLAIMS

                     Are Benefits payable from any other source (including Military, If "Yes",     (a) Other Source:
                     Automobile, Liability Insurance, School Accident Insurance) for
                     the expense submitted?                                                        (b) Address:

                                               Yes      No                                         (c) Policy No. or I.D. No.

                                                         AUTHORIZATION TO RELEASE INFORMATION
I authorize any physician, medical practitioner, hospital, clinic or other health facility, consumer reporting agency, the Medical Information Bureau,
Insurance/reinsurance company or employer to release any and all medical and non-medical information in its possession about me or my dependents to
CBCA Administrators or its legal representative. Medical information means all information in the possession of or derived from providers of health
care regarding the medical history, mental or physical condition, or treatment of me, or my dependents. I understand that CBCA Administrators will use
the information obtained by this authorization to determine eligibility for coverage and eligibility for benefits under an existing plan. CBCA
Administrators will not release any information obtained by this authorization to any person or organization except insurance/reinsurance companies, the
Medical Information Bureau, or other persons or organizations performing business or legal services in connection with my application, claim or as may
be lawfully required or permitted, or as I may further authorize. I know that I may request and receive a copy of this authorization. I agree that this
authorization shall be valid for the duration of my claim.

 Employee and Patient (Parent, if minor)                                                                                                                       Date

                        AUTHORIZATION TO PAY PROVIDER                                                                         AUTHORIZATION TO PAY PLAN PARTICIPANT
I authorize payment of all medical benefits for services rendered from those physicians or providers                Please sign below for payment to go directly to Covered person.
described below and/or as indicated on the enclosed bills. I understand that I am financially
responsible to the provider(s) for charges not covered by the authorization.


       Employee’s Signature                                                 Date                                           Employee’s Signature                                           Date



               Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self
               insured program, files a statement of claim containing any false or misleading information is guilty of a felony of the third degree.
                PART B-ATTENDING PHYSICIAN’S STATEMENT
                                                                                                             MAIL THIS FORM TO:
                                                                                                                      CBCA Administrators
 Type or Print
                                                                                                                      P.O. Box 1539
 PATIENT & COVERED PERSON (SUBSCRIBER) INFORMATION                                                                    Fort Worth, TX 76101
 1. PATIENT’S NAME (First name, middle initial, last     2. PATIENT’S SEX                                    3. WAS CONDITION RELATED TO:
    name)
                                                                                                             A. Patient’s Employment                   B. An Auto Accident
                                                              MALE           FEMALE                                YES      NO                                 YES    NO


 PHYSICIAN OR SUPPLIER INFORMATION
 4. DATE OF:       ILLNESS (FIRST SYMPTOM) OR            5. DATE FIRST CONSULTED YOU FOR THIS                6. HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS?
                   INJURY (ACCIDENT) OR                     CONDITION
                   PREGNANCY (LMP)
                                                                                                                      YES    NO

 7. DATE PATIENT ABLE           8. DATES OF TOTAL DISABILITY                                                 DATES OF PARTIAL DISABILITY
    TO RETURN TO WORK
                                FROM                                THROUGH                                  FROM                            THROUGH


 9. NAME OF REFERRING PHYSICIAN                                                                              10. FOR SERVICES RELATED TO HOSPITALIZATION GIVE
                                                                                                                 HOSPITALIZATION DATES
                                                                                                                 ADMITTED                  DISCHARGED

 11. NAME AND ADDRESS OF FACILITY WHERE SERVICES RENDERED (If other than home or office)                     12 WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE?
                                                                                                                  YES    NO CHARGES:

 13. DIAGNOSIS OR NATURE OF ILLNESS, RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE TO NUMBERS 1,2,3, ETC. OR DX CODE
 1.
 2.
 3.
 4.

 14.   A.                B*     C Fully Describe Procedures, medical Services or Supplies Furnished for           D           E                            F
                      Place     Each Date Given
 Date of Service        of                                                                                    Diagnosis     Charges
                      Service                                                                                   Code
                                Procedure Code
                                (Identify:     )             (Explain Unusual Services or Circumstances)




 15. SIGNATURE OF PHYSICIAN OR SUPPLIER                        16. ACCEPT ASSIGNMENT                         17. TOTAL CHARGE          18. AMOUNT PAID         19. BALANCE DUE
                                                                       YES           NO                                                           |                          |

                                                               20. YOUR SOCIAL SECURITY NO.                  21. PHYSICIAN’S OR SUPPLIER’S NAME, ADDRESS, ZIP CODE &
                                                                                                                  TELEPHONE NO.

       SIGNED                            DATE

 22. YOUR PATIENT’S ACCOUNT NO.                                23. YOUR EMPLOYER I.D. NO.

                                                                                                             TAX I.D. NO.

*PLACE OF SERVICE CODES
1—(IH) – INPATIENT HOSPITAL                    4—(H)-PATIENT’S HOME                               7—(NH)-NURSING HOME              10—(OL) OTHER LOCATIONS
2—(OH)—OUTPATIENT HOSPITAL                     5-- -- DAY CARE FACILITY (PSY)                     8—(SNF)—SKILLED NURSING FACILITY A—(IL)—INDEPENDENT LABORATORY
3—(O) – DOCTOR’S OFFICE                        6-- -- NIGHT CARE FACILITY (PSY)                   9-- --AMBULANCE                  B-- --OTHER MEDICAL/SURGICAL FACILITY

								
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