1199 Customer Service Details

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QuestionAnswer
Form NameAddress 1199 Seiu
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names1199 customer service, 1199 disability fax number, 646 473 9200, 1199 union contact

Form Preview Example

TO BE COMPLETED BY MEMBER

TO BE COMPLETED BY PHYSICIAN OR SUPPLIER

1199SEIU Beneit Funds

MEMBER REIMBURSEMENT

PO Box 1007, New York, NY 10108-1007

Tel: (646) 473-9200

MEDICAL CLAIM FORM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART (A): MEMBER INFORMATION

 

 

 

 

 

 

 

PART (B): PATIENT INFORMATION

 

 

 

 

 

 

 

 

 

 

1. MEMBER’S BENEFIT ID NUMBER

 

 

 

 

 

 

 

 

 

 

1. PATIENT’S NAME (First Name, middle initial, last name)

 

 

 

2. PATIENT’S DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. MEMBER’S NAME AND ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. PATIENT’S RELATIONSHIP TO SUBSCRIBER

 

 

 

4. PATIENT’S SEX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self

Spouse

Child

 

 

 

 

 

 

 

 

Male

Female

 

 

Last

 

 

 

 

 

 

First

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(please specify)

 

 

 

 

 

 

 

 

 

 

 

 

No. and Street

 

 

 

 

 

 

 

 

 

 

 

Apt. No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. IS PATIENT A DEPENDENT AGE 19 OR OVER?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF YES, PART (D) DEPENDENT CHILD INFORMATION ON REVERSE SIDE MUST BE COMPLETED.

 

 

City

 

 

 

 

 

State

 

 

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6a. WAS INJURY OR CONDITION RELATED TO:

 

 

 

 

 

 

 

 

 

 

Telephone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. PATIENT’S EMPLOYMENT

YES

NO

 

 

 

 

 

 

 

 

 

 

3. MEMBER’S EMPLOYER

 

 

 

 

 

 

 

 

 

 

B. ACCIDENT

AUTO

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6b. IF ACCIDENT, GIVE DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3a. Job Title

 

 

 

 

4. DATE OF BIRTH

 

 

 

SEX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

Year

 

 

 

 

 

6c. IS OR WILL LEGAL ACTION BE TAKEN?

 

YES

 

NO

 

 

 

 

 

 

 

5. CHECK

 

 

Single

Widowed

Legally

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6d. LAWYER’S NAME AND ADDRESS, IF ANY:

 

 

 

 

 

 

 

 

 

 

5. ONE BOX

 

Married

Divorced

Separated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6a. Are you or your dependent/spouse covered under any other group plan?

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6b. If yes, complete:

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. I AUTHORIZE THE RELEASE TO OR BY NBF OF ANY MEDICAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NECESSARY TO PROCESS THIS CLAIM.

 

 

 

 

 

 

 

 

 

 

 

Name of person covered

 

 

 

 

Relationship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Member of Spouse

 

 

 

 

 

 

 

 

 

 

 

Dated

 

Name and address of person’s employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED PHYSICIAN OR SUPPLIER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. FOR SERVICE DESCRIBED BELOW.

 

 

 

 

 

 

 

 

 

 

 

6c. Plan name and number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dated

 

6d. Effective date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART (C): PHYSICIAN OR SUPPLIER INFORMATION–Please complete all items

 

 

 

 

 

 

 

 

 

 

 

1. Date of First Treatment for Condition

 

 

 

2. Is this an initial consultation?

 

 

 

 

 

 

3. Is condition due to injury or sickness arising out of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

3. patient’s employment?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

4. For service related to hospitalization,

 

 

 

Name of Hospital

 

 

 

 

 

 

 

 

 

5. Name and Address of Referring Physician

 

 

 

give hospitalization dates:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Admitted

 

 

 

 

 

Discharged

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Will any claim for the services below be iled with any other insurance carrier or beneit provider?

 

 

 

 

 

 

 

 

 

 

 

6a. NPI #

 

 

 

 

 

Yes

No

 

If yes, please specify

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. Preventive

 

 

Diagnosis or nature of illness or injury (if diagnosis code other than ICD9*, give name)

 

 

 

 

 

 

 

 

 

 

 

ICD9 CODE

 

 

7. checkup?

 

 

1. Primary

 

 

 

 

 

 

 

 

 

 

3. Secondary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

2. Secondary

 

 

 

 

 

 

 

 

 

 

4. Secondary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. REPORT OF SERVICES (or attach itemized bill).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of

 

 

 

Place of

 

 

Description of Surgical or Medical Services Rendered

 

 

 

 

Procedure Code, if used (If code

Charges

 

 

Services

 

 

Services†

 

 

 

 

 

other than CPT4 * * used, give name)

DO-Doctor’s Ofice

 

IH-Inpatient Hospital

NH-Nursing Home

 

 

 

 

 

 

 

TOTAL CHARGES

$

H-Patient’s Home

 

OH-Outpatient Hospital

OL-Other Locations

 

 

 

 

 

 

 

AMOUNT PAID

$

*ICD9-International Classiication of Diseases

 

 

 

 

 

 

 

 

 

 

* *CPT-Current Procedural Terminology (current edition)

 

 

 

 

 

 

 

 

 

 

BALANCE DUE

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. Physician’s name (print)

 

 

 

 

 

 

 

 

 

10.

Specialty

 

 

11. Physician’s signature

 

 

 

 

 

 

 

 

 

 

12.

Date

 

 

13. Street address

 

 

 

 

City

 

State

 

 

Zip Code

 

 

14. Telephone (

)

 

15. Indv. Practitioner’s SS#

 

 

NPI #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: If you are accepting an assignment of beneits, please complete Item No. 15 to avoid delay in payment.

PART (D): DEPENDENT CHILD INFORMATION

This part must be completed each time a claim is submitted for a dependent child age 19-23.

 

 

DEPENDENT

 

 

 

(print) Last Name

Init. First Name

 

 

 

 

Date of Birth

Social Security No.

Is the dependent employed? If yes, give name and address of dependent’s employer:

Dependent’s Employer

 

Address

Dependent is employed

Full Time

Part Time

My dependent child listed above is not married, is principally dependent upon me for maintenance and sup- port, is under 23 years of age, and is my natural or adopted child.

Member’s Signature

Date

PART (E): CLAIM FILING INSTRUCTIONS

Mail this CLAIM FORM promptly. Follow these instructions to avoid delay.

1.Member must complete Parts A and B of Claim Form.

2.Complete Part D if claim is for a dependent child age 19-23.

3.Have your physician or supplier complete Part C.

4.The completed Claim Form should be mailed to the Fund within 30 days of the date the services were provided.

5.A separate claim form must be completed for each patient.

6.If the Fund is not your primary insurer, you must attach a copy of the payment voucher from the other plan.

Mail your form to: 1199SEIU Beneit Funds

Times Square Station

PO Box 1007

New York, NY 10108-1007

1098-M

3AF29M • 10/09 • 47181

 

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