Asuris Form Pd017 – Fill Out and Use This PDF

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

No

Vision Coverage?

Yes

No

Dental coverage?

Yes

No

With Orthodontia?

Yes

No

Prescription Coverage?

Yes

No

If YES, is this coverage

Group

Individual

Are you or any family members covered by Medicare?

Yes

No

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)