Asuris Form Pd017 – Fill Out and Use This PDF

The Asuris PD017 form serves as a crucial instrument for members seeking reimbursement for health care expenses incurred outside the network of participating providers. This comprehensive form is designed to navigate policyholders through the reimbursement process, ensuring they provide all necessary information regarding their healthcare services, whether it be medical, dental, or vision. To streamline the claim submission process and facilitate a smooth reimbursement experience, complete and submit the form attentively. For ease in submitting your reimbursement request, click the button below.

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Asuris Form Pd017 PDF Details

Navigating the complexities of healthcare insurance reimbursement can seem daunting, but the Asuris Pd017 form serves as a vital tool for members looking to request reimbursements for healthcare services. This straightforward form is designed for use when services have been received from providers outside of the Asuris network, or in instances where a service provider has not submitted a claim. To ensure clarity and ease of processing, the form requires detailed member information, including patient identification, policyholder details, and any relevant information regarding other insurance coverage. Members are instructed to attach original receipts—excluding cash register receipts—to substantiate their claims and are reminded of the necessity to retain copies for their personal records. Additionally, the form includes sections aimed at capturing the specifics of any other insurance policies that may cover the member, including details for medical, vision, dental, and prescription coverage, as well as Medicare specifics if applicable. Providing comprehensive instructions on how to fill out and submit the form, along with the requirement for the patient or policyholder’s signature for authorization, the Asuris Pd017 form emphasizes its role in facilitating the reimbursement process for its members, ensuring they understand the steps required to file a claim properly.

Question	Answer
Form Name	Asuris Form Pd017
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names

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DIRECT MEMBER REIMBURSEMENT FORM

Thank you for choosing us for your health insurance coverage. Use this claim form for any reimbursement requests you may have. If you received services from a participating provider, your claim should be submitted by the provider; therefore, you do not need to submit this form unless you know that your claim was not submitted. Please complete a separate form for each family member, pharmacy or provider (print additional copies of page 2 if necessary). For claim filing time limits, review your benefit information.

1.Complete the information below and where indicated on the following page.

2.Write your ID number on the top of each page.

3.Tape your original receipts in the boxes marked for receipts; cash register receipts will not be accepted.

4.Retain copies of receipts for your records. Receipts will not be returned.

5.Sign the completed form where indicated at the bottom of this page and mail to:

Asuris Northwest Health

PO Box 21267

Seattle, WA 98111-3267

MEMBER INFORMATION

Patient's Name (Last, First, M.I.)

Patient's Date of Birth

Patient's Sex

Male

Female

Policyholder's Name (Last, First, M.I.)

Patient's Relationship to Policyholder

Self

Spouse

Dependent

Policyholder's Street Address

City

State

ZIP Code

Telephone Number

Patient's ID Number

Group Name

Group Number

OTHER INSURANCE INFORMATION

Are you or ANY family members on this policy covered by other:

Medical coverage?

Yes

Vision Coverage?

Yes

Dental coverage?

Yes

With Orthodontia?

Yes

Prescription Coverage?

Yes

If YES, is this coverage

Group

Individual

Are you or any family members covered by Medicare?

Yes

If YES:

Part A

Part B

Part D

IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS "YES," please complete the section regarding the other insurance. If there are more than one additional policy, attach the quested information for each policy on a separate sheet of paper.

Name of Other Insurance

Subscriber's Name

ID Number

Date of Birth

Subscriber's Relationship to

Asuris Policyholder

Street Address for Submitting Claims

City

State

ZIP Code

This other insurance covers:

If covered children are from divorced parents, indicate name of person with legal custody

Asuris Policyholder's Spouse

Asuris Policyholder

Dependents

Name of Subscriber's Employer

Active

Retiree

Effective Date of this Plan

Please indicate why the patient paid in cash

I certify that the above statements are correct and hereby authorize any physician, hospital, employer, union, insurance company, or prepayment organization to supply my employer and its agents any information required in connection with this claim. A photocopy of this authorization shall be as valid as the original.

Signature (Subscriber or Patient)

Date

FORM PD017 - Page 1 of 2 (Rev. 7/12)

Prescription (Rx) receipts must contain:	Medical, Dental and Vision receipts must contain:
Rx Number	Provider's Name and Address
Date Rx was filled	Tax Identification Number
Provider's Name	Diagnosis and Procedure Codes
Drug Name and NDC Number	Date of Service
Quantity and days supply	Itemized Charges
Charge

Contact the provider or pharmacy if you need additional information

TAPE RECEIPT HERE

In date order

TAPE RECEIPT HERE

In date order

Nature of Illness or Injury

Doctor's Name (If not on receipt)

If Injury, Date Occurred

How, When, Where