Memorial Care Eligibility Form – Fill Out and Use This PDF

Assignment of Insurance Benefits/Eligibility Certification

MRN: ___________

Prima ry Insura nc e Pla n

Patient Name

Date of Birth

Insurance Plan

Group #

Policy #

Insurance Company Address

Phone #

Subscriber Name

Relationship to Patient

Subscriber Certificate/Social Security #

Subscriber Date of Birth

Subscriber Employer

Employer Phone #

Employer Address

Fo r Me dic a re Pa tie nts O nly

Health Insurance Claim #

Part A Effective Date

Part B Effective Date

O the r Insura nc e C o ve ra g e fo r Pa tie nt

Patient Name

Date of Birth

Insurance Plan

Group #

Policy #

Insurance Company Address

Phone #

Subscriber Name

Relationship to Patient

Subscriber Certificate/Social Security #

Subscriber Date of Birth

Subscriber Employer

Employer Phone #

Employer Address

฀ I hereby authorize and request that payment of

฀ I understand that I am eligible for benefits through

authorized Medicare/other insurance company benefits

my HMO policy.

I understand that my assigned

be made on my behalf, be paid directly to MemorialCare

IPA/Medical Group chosen for my benefits is a

Medical Foundation for any medical or surgical services

MemorialCare Medical Foundation affiliated medical

rendered by its affiliated medical groups to me or a

group listed above.

I am aware that if the above is not

member of my family. I authorize any holder of medical

true, I (or the person financially responsible for me) am

or other information about me to release to the Social

responsible for all charges related to services provided to

Security Administration, Health Care Financing

me. I agree that if the above is not true, I (or the person

Administration, its agents or carriers, or the insurance

financially responsible for me), will pay in full all such

company any information needed for this or a related

charges.

Medicare/other insurance claim to determine these

benefits or the benefits payable for related services. I

understand that it is mandatory to notify the healthcare

provider of any other party who may be responsible for

paying for my treatment.

__________________________________________

________________________________________

Signature of Patient /Responsible Party

Date

__________________________________________

________________________________________

Name of Patient/Responsible Party (please print)

Relationship to Patient