Key Benefit Request Form – Fill Out and Use This PDF

The Key Benefit Request form is a critical document designed to facilitate the process of requesting medical benefits from Key Benefit Administrators. It requires detailed patient and treatment information, including patient identification, diagnoses, treatment details, and provider information, to be completed and submitted correctly. For those needing to complete this form, a clickable button below offers a straightforward way to begin this important step.

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Key Benefit Request Form PDF Details

At the heart of many healthcare transactions, especially those involving claims and requests for benefits, lies a crucial piece of documentation known as the Key Benefit Request Form. This document, which must be carefully filled out and submitted to Key Benefit Administrators, Inc., is instrumental in ensuring that patients receive the healthcare benefits they are entitled to. The form requires detailed patient information, including the patient's name, date of birth, and the relationship to the insured, reflecting the necessity for precise and accurate data collection in the healthcare industry. Details about the patient's condition or injury, whether it resulted from an accident, and any other health insurance coverage are critical components of this form. Additionally, it gathers specifics regarding the patient's visit to the physician or supplier, including diagnosis, treatments provided, and the associated costs. This form not only serves as a request for payment from insurance providers but also as a legal document that authorizes the release of medical information necessary to process the claim. What makes the Key Benefit Request Form significant is its role in bridging gaps between patients, healthcare providers, and insurance companies, ensuring that the process of claiming benefits is as smooth as possible.

Question	Answer
Form Name	Key Benefit Request Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	129
Avg. time to fill out	26 min 3 sec
Other names	po box 3252 milwaukee wi 53201 provider phone number, po box 3252 milwaukee wi 53201 phone number, po box 3252, key benefit administrators payer id

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BENEFIT REQUEST FORM TYPE OR PRINT

Submit To:	Key Benefit Administrators, Inc.
	P.O. Box 2050
	Fort Mill, SC 27916-2050

PATIENT INFORMATION (TO BE COMPLETED BY EMPLOYEE)

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

2. PATIENT’S DATE OF BIRTH

3. EMPLOYEE’S NAME AND ADDRESS

FULL TIME STUDENT

YES

NO IF YES, WHERE

4. PATIENT’S ADDRESS (if different from employee)

5. PATIENT’S SEX

6. EMPLOYEE’S SOC. SEC. NO.

MALE

FEMALE

7. PATIENT’S RELATIONSHIP TO INSURED

8. GROUP NAME (e.g. employer)

SELF

SPOUSE

CHILD OTHER

9. OTHER HEALTH INSURANCE COVERAGE

10. WAS CONDITION RELATED TO:

11. IF AN ACCIDENT

YES

If yes, Enter Name of Policyholder and Plan Name

A. PATIENT’S EMPLOYMENT

date______________20______and time______

and Address and Policy or Medical Assistance

YES

description (how & where)

Number

AN ACCIDENT

YES

12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE

13. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED

I authorize the Release of any Medical Information Necessary to Process this request.

PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW.

SIGNED:DATE:

SIGNED (Employee or Authorized Person)

PHYSICIAN OR SUPPLIER INFORMATION (TO BE COMPLETED BY PHYSICIAN AND RETURNED TO EMPLOYEE)

14.

DATE OF:

ILLNESS (FIRST SYMPTOM) OR

15. DATE FIRST CONSULTED YOU FOR

16. HAS PATIENT EVER HAD SAME

INJURY (ACCIDENT) OR

THIS CONDITION

OR SIMILAR SYMPTOMS?

PREGNANCY (LMP)

YES

17.

DATE PATIENT ABLE TO

18. DATES OF TOTAL DISABILITY

DATES OF PARTIAL DISABILITY

RETURN

TO WORK

FROM

THROUGH

FROM

THROUGH

19.

NAME OF REFERRING PHYSICIAN

20. FOR SERVICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION

DATES

ADMITTED

DISCHARGED

21.

NAME & ADDRESS OF FACILITY WHERE SERVICES RENDERED (if other than home

22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE?

or office)

YES

CHARGES:

23.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATED TO PROCEDURE IN COLUMN D BY REFERENCE TO NUMBERS 1, 2, 3, ETC. OR DX CODE

24. A	B	C FULLY DESCRIBE PROCEDURES, MEDICAL SERVICES OR
DATE	PLACE	SUPPLIES FURNISHED FOR EACH DATE GIVEN			D	E	F
OF	OF				DIAGNOSIS
		PROCEDURE CODE		(EXPLAIN UNUSUAL SERVICES OR
SERVICE	SERVI-				CODE	CHARGES
		(IDENTIFY:	)
	CE			CIRCUMSTANCES)

25. SIGNATURE OF PHYSICIAN OR SUPPLIER

26.

27. TOTAL CHARGE

28.

29.

AMOUNT PAID

BALANCE DUE

30.

YOUR SOC. SEC. NO.

31. PHYSICIAN’S OR SUPPLIER’S NAME, ADDRESS, ZIP CODE & PHONE NO.

SIGNED

DATE

32. YOUR PATIENT’S ACCOUNT NO.

33.

YOUR EMPLOYER ID NO

*PLACE OF SERVICE CODES

1-(IH)-INPATIENT HOSPITAL

4-(H)-PATIENT’S HOME

7-(NH)-NURSING HOME

O-(OL)-OTHER LOCATIONS

2-(OH)-OUTPATIENT HOSPITAL

5- DAYCARE 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

*PLEASE USE CURRENT PROCEDURAL TERMINOLOGY CODES FOR SURGERY

How to Edit Key Benefit Request Form Online for Free

The concept powering our PDF editor was to permit it to be as convenient as possible. You will find the whole procedure of filling in po box 3252 easy when you follow all of these steps.

Step 1: On this page, hit the orange "Get form now" button.

Step 2: When you have entered the po box 3252 edit page, you'll discover all actions it is possible to use concerning your document at the upper menu.

These parts will compose the PDF document that you'll be filling out:

entering details in key benefits administrators claims address part 1

You should provide the crucial details in the ADMITTED, DISCHARGED, YES, CHARGES, DATE, PLACE, SERVICE, SER, VI PROCEDURE, CODE, IDENTIFY DIAGNOSIS, CODE, CHARGES, TOTAL, CHARGE AMOUNT, PAID and BALANCE, DUE field.

key benefits administrators claims address ADMITTED, DISCHARGED, YES, CHARGES, DATE, PLACE, SERVICE, SERVI, PROCEDURECODEIDENTIFY, DIAGNOSIS, CODE, CHARGES, TOTALCHARGE, AMOUNTPAID, and BALANCEDUE blanks to fill

You may be asked to provide the information to let the software prepare the part YOUR, SO, CSEC, NO, YOUR, EMPLOYER, ID, NO and YOUR, PATIENTS, ACCOUNT, NO

key benefits administrators claims address YOURSOCSECNOYOUREMPLOYERIDNO, and YOURPATIENTSACCOUNTNO fields to fill out

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Step 4: To prevent yourself from any sort of challenges later on, try to prepare as much as a couple of duplicates of your form.

Key Benefit Request Form – Fill Out and Use This PDF

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