Key Benefit Request Form – Fill Out and Use This PDF

The Key Benefit Request Form is a document requesting data regarding the benefits of using your product or service.

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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.

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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

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

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

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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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Key Benefit Request Form – Fill Out and Use This PDF

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