Google Docs Fax Cover Sheet PDF Details

In today’s fast-paced world, the essence of efficient communication is paramount, especially in the realm of healthcare where timely information exchange can significantly influence patient care and insurance matters. Enter the Google Docs Fax Cover Sheet form, an integral tool designed to streamline the process of transmitting healthcare claims between patients, providers, and insurers. Tailored specifically for use by members of the PricewaterhouseCoopers Group, this form encompasses essential details such as member and patient information, accident insights, other insurance coverage, and guidelines for submitting claims to UnitedHealthcare. This comprehensive document not only facilitates a smoother claim submission process but also underscores the importance of accuracy and honesty in filling out medical claims, as it sternly warns against the legal repercussions of submitting false information. Significantly, it includes provisions for accident information, showcasing its utility in a wide array of scenarios, and an assignment of benefits section, which allows for direct payment to service providers. With its thorough compilation of necessary data points — from subscriber and patient specifics to detailed instructions on claim submission — this fax cover sheet epitomizes a crucial bridge in the healthcare communication network, ensuring that critical information is relayed succinctly and securely.

QuestionAnswer
Form NameGoogle Docs Fax Cover Sheet
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesgoogle fax cover sheet template, fax cover sheet template google docs, editable fax cover sheet template google docs, google docs fax cover sheet template

Form Preview Example

PricewaterhouseCoopers

Group # 752713

Member Services: (888) 792-1545

For Medical Claims:

For Mental Health/Substance Use Claims:

PO Box 740809

PO Box 30760

Atlanta, GA 30374-0809

Salt Lake City, UT 84130-0760

Fax #: (248) 733-6000

Fax #: (248) 733-6079

HEALTH CLAIM TRANSMITTAL

A. SUBSCRIBER/EMPLOYEE INFORMATION

Subscriber/Member #:

 

 

 

 

 

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last

 

 

 

 

First

 

 

 

 

 

 

 

 

MI:

Date of Birth:

Name:

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

Home

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address: Yes No

City:

 

 

 

 

 

 

 

 

 

State:

 

 

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Code:

Spouse

 

 

 

 

First

 

 

 

 

 

 

 

 

MI:

Spouse Date of Birth:

Last Name:

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

B. PATIENT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

Last

 

 

 

 

First

 

 

 

 

 

 

 

 

MI:

Date of Birth:

Name:

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

Home

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

State:

 

 

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Code:

Sex:

Relationship

 

 

 

 

Full Time Student:

School

 

 

 

 

School Phone #:

M F

To subscriber:

 

 

 

 

Yes

No

Name:

 

 

 

 

 

 

C. ACCIDENT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

Work

 

 

 

 

 

 

Auto

 

 

 

 

 

 

 

Date Accident

 

 

 

Accident?

Yes

No

 

 

 

Accident:

Yes

 

No

 

 

Occurred:

 

 

 

How did the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accident Occur:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D. OTHER INSURANCE

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the patient covered

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

by another plan?

Yes

No

If yes, please complete the following

 

 

 

Name of the person

 

 

 

 

 

 

 

 

 

 

Date of Birth:

 

 

 

carrying other insurance:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member #:

 

 

 

 

 

 

 

 

 

 

 

 

Name of Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Carrier:

 

 

 

Policy

 

 

 

 

 

 

 

 

 

 

 

 

Employer

 

 

 

Number:

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY MISREPRESENTATION OR

ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE GUILTY OF A CRIMINAL ACT PUNISHABLE

 

 

 

 

UNDER LAW AND MAY BE SUBJECT TO CIVIL PENALTIES.

 

 

 

Member Signature:

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E. ASSIGNMENT OF BENEFITS

Please sign below only if you want UnitedHealthcare to pay benefits directly to the provider of medical/mental health/ substance abuse services.

Signature:Date:

F. GUIDELINES FOR SUBMITTING CLAIMS TO UNITEDHEALTHCARE

•Clip, do not staple, all bills to the completed form and mail them to UnitedHealthcare at the address listed on your ID card at the address on top of this claim form.

•Submit all claims to UnitedHealthcare ina timely manner.

•Be sure to notify your employer of alladdress changes.

•Please include your Subscriber Number or Member Number on all documents.

Make sure that all bills include the following:

•Employee and Member information including address

•Patient and/or guardian name

•Diagnosis code from the provider

•Dates of Service – Each date of service should be specified

•Place of Service – Physician’s Office, Outpatient Facility, etc.

•CPT Codes

•Billed amount

•Provider tax id number

•Claim total

•Name of provider

•Address where services were rendered

•Billing Address

How to Edit Google Docs Fax Cover Sheet Online for Free

It is easy to obtain forms working with our PDF editor. Revising the 248 733 6000 document is not difficult should you keep up with the following actions:

Step 1: You can press the orange "Get Form Now" button at the top of the following website page.

Step 2: You can see each of the actions that you may take on your document once you have accessed the 248 733 6000 editing page.

To be able to obtain the document, enter the data the software will ask you to for each of the next areas:

part 1 to filling in google docs fax cover sheet

The software will require you to submit the Work Accident How did the Accident, Yes, D OTHER INSURANCE, Auto Accident, Yes, Date Accident Occurred, Is the patient covered by another, Yes, Policy Number, If yes please complete the, Name of Other Insurance Carrier, ANY PERSON WHO KNOWINGLY FILES A, Member Signature, Date, and E ASSIGNMENT OF BENEFITS area.

stage 2 to completing google docs fax cover sheet

Step 3: Select "Done". Now you can transfer the PDF file.

Step 4: Ensure you avoid possible future difficulties by creating around two duplicates of your file.

Watch Google Docs Fax Cover Sheet Video Instruction

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