Key Benefit Request Form PDF Details

Today, businesses have to be able to track requests and manage customer feedback in an organized way. The Key Benefit Request Form is a tool that can do just that. This form allows businesses to easily keep track of customer requests, as well as customer complaints and suggestions. By having this form, businesses can improve their customer service and keep track of what needs to be fixed or improved. The Key Benefit Request Form also helps with keeping communication open between the business and the customer. This form is an essential tool for any business! Use this key benefit request form to improve your customer service! Keep track of customer feedback, suggestions, and complaints in one place. Improve communication with your customers with this easy-to-use form.

We have collected some useful information about the key benefit request form. You might like to read it prior to typing in the form.

QuestionAnswer
Form NameKey Benefit Request Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameskey benefit administrators claims mailing address, key benefit administrators, po box 3252 milwaukee wi 53201 phone number, po box 3252 milwaukee wi 53201 provider phone number

Form Preview Example

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

NO

 

 

 

 

 

 

 

 

 

 

 

 

AM

If yes, Enter Name of Policyholder and Plan Name

A. PATIENT’S EMPLOYMENT

 

date______________20______and time______

PM

and Address and Policy or Medical Assistance

 

 

 

YES

NO

 

description (how & where)

 

 

 

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

AN ACCIDENT

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

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

NO

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

NO

 

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

1.

2.

3.

4.

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

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