Medpartners Cob Online Form PDF Details

Are you looking for an efficient way to manage and submit forms related to insurance claims, billing processes, and more online? MedPartners Cob Online Form simplifies the document registration process by making it easy and secure. This comprehensive solution offers a one-stop shop for securing patient information that is immediately available at newly established healthcare locations. With an intuitive interface and customizable database, it’s no surprise why this platform is quickly becoming one of the most sought after medical solutions on the market today.

QuestionAnswer
Form NameMedpartners Cob Online Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescob online form sample, cob online form template, of form cob questionnaire, form med partners online

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P.O. Box 2602

Fort Wayne, IN 46801

COORDINATION OF BENEFITS QUESTIONNAIRE

This form MUST be completed to notify MedPartners Administrative Services of Medicare or other health insurance coverage for Coordination of Benefits (COB). FAILURE TO COMPLETE THIS FORM WILL RESULT IN DELAYS

TO CLAIM PAYMENTS.

PLEASE CHECK REASON FOR SUBMISSION:

Annual COB update New enrollee Add other insurance Termination of other insurance

Add dependent/spouse

Group Policy # ________________

Group or Employer Name

__________________________________________

Member ID # __________________

Member/Employee Name

__________________________________________

Address ______________________________________________________ Phone # ________________________

ARE YOU OR ANY OF YOUR COVERED DEPENDENTS ALSO COVERED BY ANOTHER GROUP HEALTH PLAN?

NO – Please skip the rest of the questions, sign at the bottom, and return.

YES – Complete entire form, sign, and return.

SECTION 1 OTHER HEALTH COVERAGE INFORMATION (Excluding Medicare – See Section 3)

Please provide information about policy holder of the other health coverage. Attach additional pages if needed.

Name of policy holder of other coverage

Relationship to you

 

Social Security #

 

Employer

 

 

 

Birth date

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance company name

 

Insurance company address

 

 

 

 

 

 

Phone #

 

 

 

 

 

 

 

 

 

 

 

 

Member ID/Policy #

 

Group #

 

 

 

 

Effective date

 

Cancellation date

 

 

 

 

 

 

 

 

 

 

Type of coverage: Single

Family

 

Type of Plan:

Medical

Dental

Vision

Prescription Drug

 

 

 

 

 

 

 

 

 

 

 

Who is covered by this other plan? Include yourself if applicable.

 

 

 

 

 

 

 

 

 

 

Name (First and Last)

 

 

 

Relationship to You

Effective Date

Cancellation Date

1.

______________________________________________________

_____________________

________________

________________

2.

______________________________________________________

_____________________

________________

________________

3.

______________________________________________________

_____________________

________________

________________

4.

______________________________________________________

_____________________

________________

________________

5.

______________________________________________________

_____________________

________________

________________

6.

______________________________________________________

_____________________

________________

________________

NOTE: For dependent children of divorced, separated, or court-ordered parents, PLEASE complete SECTION 2.

COB FORM 11_19_08

SECTION 2 SPECIAL SITUATIONS FOR DEPENDENT CHILDREN

Fill out this section only if any of your children have health care coverage in addition to the above because of divorce, separation, etc.

Is there a court order that determines responsibility for health care coverage or custody?

No Yes – Attach copy of applicable section pertaining to custody and/or health care coverage.

Who does the court order indicate is responsible for insurance/health coverage? ______________________________________________________

Person responsible for child’s health care coverage

Social Security #

Relationship

Employer

 

 

Birth date

 

 

 

 

 

 

 

 

Insurance company name

Insurance company address

 

 

Phone #

 

 

 

 

 

 

Member ID/Policy #

Group #

 

Effective date

Cancellation date

 

 

 

 

 

 

 

 

Which children are covered by this insurance?

 

 

 

 

Child’s Name (First and Last)

Who has custody?

 

Child’s Name (First and Last)

Who has custody?

1.

___________________________

___________________________

4.

____________________________

__________________________

2.

___________________________

___________________________

5.

____________________________

__________________________

3.___________________________ ___________________________ 6. ____________________________ __________________________

SECTION 3 MEDICARE COVERAGE

If you or your spouse has Medicare coverage, please complete the following:

Are you covered by Medicare? No

Yes

Actively Employed

Retired

Reason for coverage:

Over 65

Disabled

ESRD (End Stage Renal Disease)

Hospital Part A: Effective Date _______________________

 

 

Hospital Part B: Effective Date _______________________

 

 

Is your spouse covered by Medicare?

No

Yes

Actively Employed

Retired

Reason for coverage:

Over 65

Disabled

ESRD (End Stage Renal Disease)

Hospital Part A: Effective Date _______________________

 

 

Hospital Part B: Effective Date _______________________

 

 

MEMBER’S SIGNATURE ____________________________________________

DATE ________________________

Return completed form to: MedPartners Administrative Services

OR

Fax to: (260) 435-7513

P.O. Box 2602

 

 

Fort Wayne, IN 46801

 

 

COB FORM 11_19_08