Pomco Form – Fill Out and Use This PDF

The Pomco form serves as a comprehensive Medical/Surgical/Major Medical Benefit Request document designed for use by individuals covered under specific health plans, such as those administered by Bedford Schools. It outlines necessary information about the patient, their relationship to the employee, details on the treatment required, and employment data, all of which are critical for processing healthcare benefits accurately. For a smooth and efficient claim process, ensure all sections are filled out correctly. To proceed with your claim, please click the button below.

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Pomco Form PDF Details

Navigating through healthcare forms can sometimes feel like deciphering an ancient script. The Pomco form is a crucial document for employees covered under Bedford Schools' health plan, simplifying the process of submitting medical, surgical, or major medical benefit requests. Located in Syracuse, NY, the form is designed to streamline communication between patients, healthcare providers, and the insurer. It covers essential patient information, including personal details, employment, and the nature of the treatment or injury. Notably, the form addresses cases where treatment results from accidents, whether auto-related or otherwise, and determines if the treatment is for a work-related condition. It also inquires about any other health benefit plans that may cover the patient, laying the groundwork for coordination of benefits. By requiring signatures to authorize information sharing and payment to healthcare providers, the form upholds transparency and consent. Instructions on the reverse side aim to minimize errors and delays by guiding patients on how to correctly fill out the form, including a reminder of the potential legal repercussions of submitting false information. This comprehensive approach ensures that claims are processed efficiently, benefiting both the claimants and the administrators of the health plan.

Question	Answer
Form Name	Pomco Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	medical form pomco ny, pomco claims address, pomco prior authorization form, pomco select firmagon authoriation forms

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O Y E E

P H Y S I C I A N

PLAN

ADM I NI STERED BY

Bedford Schools

RETURN TO:

HEALTH PLAN

POM CO

P.O. BOX

6329

SYRA CUSE, NY 13217

Tel : 1-800-234-9862

MEDI CAL/ S URGI CAL/ MAJ OR MEDI CAL BENEFI T REQUES T

FORM

PA TIENT INFORM A TION SECTION

1 .

PATI ENT NAM E

2 .

RELATI ONSH I P TO EM PLOYEE

3 .

SEX

4 .

PATI ENTS DATE OF BI RTH

SELF SPOU SE

C H I LD

OTH ER

M ONTH

DAY

YEAR

5 . I F FU LL TI M E STU DENT GI VE NAM E AND ADDRESS OF SC H OOL AND YEAR OF GRADU ATI ON

6 .

EM PLOYEE NAM E

7 .

EM PLOYEE SOC I AL SEC U RI TY NU M BER

FI RST

M I DDLE

LAST

8 .

EM PLOYEE M AI LI NG ADDRESS

EM PLOYEE' S BI RTH DATE

9 .

EM PLOYER

Bedford Schools

Plan 940

C I TY, STATE,

Z I P

1 0 . I S TREATM ENT A RESU LT OF AN AU TO AC C I DENT?

YES I F YES, GI VE DESC RI PTI ON AND DATE.

1 1 .

I S TH E TREATM ENT A RESU LT OF AN AC C I DENT?

YES

I F YES PLEASE DESC RI BE.

H OW , W H EN AND W H ERE?

I S TREATM ENT DU E TO A

W ORK- RELATED C ONDI TI ON?

YES

1 2 .

I S YOU R SPOU SE EM PLOYED? SPOU SE' S NAM E

SPOU SE' S BI RTH DATE

SPOU SE' S SOC I AL SEC U RI TY NU M BER

YES NO

1 3 .

NAM E, ADDRESS AND PH ONE NU M BER OF SPOU SE' S EM PLOYER

1 4 .

I S TH E PATI ENT, YOU R SPOU SE, YOU RSELF, OR ANY OTH ER FAM I LY M EM BER C OVERED BY ANOTH ER H EALTH BENEFI T PLAN?

NAM E OF FAM I LY M EM BER C OVERED

YES

I F YES,

ANSW ER Q U ESTI ON 1 5 .

1 5 .

H EALTH PLAN NAM E

GROU P NU M BER

NAM E AND ADDRESS OF OTH ER H EALTH I NSU RANC E C OM PANY

1 6 .

I C ERTI FY TH E I NFORM ATI ON GI VEN BY M E I S C OM PLETE AND C ORREC T, AND TH AT I AM C LAI M I NG BENEFI TS ONLY FOR C H ARGES I NC U RRED BY TH E PATI ENT NAM ED.

I AU TH ORI Z E ANY PH YSI C I AN OR H OSPI TAL TO PROVI DE PERTI NENT REC ORDS TO POM C O U PON REQ U EST TO ESTABLI SH M Y C LAI M FOR BENEFI TS U NDER TH I S PLAN.

SI GNATU RE OF C OVERED EM PLOYEE

DATE

1 7 .

I AU TH ORI Z E POM C O TO PAY ANY BENEFI TS DU E TO TH E PROVI DER I H AVE I NDI C ATED.

SI GNED (EM PLOYEE)

DATE

PLEASE PAY DR.

PHYSICIA N OR PROVIDER INFORM A TION (SEE REVERSE FOR I NSTRU C TI ONS)

1 8 . ONSET OF I NJU RY OR I LLNESS

1 9 . DATE FI RST C ONSU LTED BY YOU

2 0 . I F EM ERGENC Y I LLNESS OR I NJU RY,

BRI EFLY DESC RI BE.

FOR TH I S C ONDI TI ON

PLACE

OF S ERVI CES CODES

2 1 . DI AGNOSI S OR NATU RE OF I LLNESS OR I NJU RY

H -

H OSPI TAL

OFFI C E VI SI TS

L -

LAB

OP - OU TPATI ENT

OTH ER

DATE OF SERVI C E

PLAC E OF SER-

DI AGNOSTI C C ODE

PROC EDU RE C ODE

FU LLY DESC RI BE PROC EDU RES, M EDI C AL SERVI C ES OR SU PPLI ES

FEE

VI C E C ODE

(I C D, DSM )

(C PT- 4 )

FU RNI SH ED FOR EAC H

DATE GI VEN

PROVI DER NAM E AND ADDRESS		TOTAL FEE C H ARGED

		AM OU NT PAI D
C I TY, STATE, Z I P	TAX PAYER I DENTI FI C ATI ON NU M BER
		BALANC E DU E


I HEREBY CERTI FY THAT THE PROCEDURES	I NDI CATED BY DATE HAVE BEEN COMPLETED.
DOC TOR' S
SI GNATU RE		DATE

PH ONE NU M BER

Bedford Schools

HEALTH PLAN

HOW TO REQUEST BENEFITS

1 . COM PLETE ITEM S 1 THROUGH 1 0 UNDER THE PATIENT INFORM ATION SECTION. IF YOU ARE M ARRIED, OR HAVE OTHER HEALTH BENEFITS, ITEM S 1 2 ,1 3 ,1 4 , AND 1 5 M UST BE COM PLETED. IF ANY INFORM ATION IS M ISSING, IT WILL DELAY THE PAYM ENT OF YOUR CLAIM .

2 . HAVE YOUR DOCTOR COM PLETE THE PHYSICIAN'S INFORM ATION SECTION, OR SUBM IT COM PLETELY ITEM IZED BILLS. AN ITEM IZED BILL M UST CONTAIN: PATIENT'S NAM E, RELATIONSHIP, DATE OF SERVICE, TYPE OF SERVICE RENDERED, NATURE OF CONDITION BEING TREATED. IF THIS INFORM ATION IS M ISSING, YOU M AY WRITE IT ON THE BILL, AND SIGN YOUR NAM E. IF YOU GO TO A NON- PARTICIPATING PHARM ACY OR DO NOT USE YOUR PRE- SCRIPTION DRUG CARD, COM PLETE A SEPARATE PRESCRIPTION DRUG CLAIM FORM .

3 . IF YOU WANT BENEFITS PAID TO YOUR DOCTOR, OR PROVIDER DIRECTLY, BE SURE TO SIGN ITEM 1 7 .

4 . COM PLETE A SEPARATE CLAIM FORM FOR EACH FAM ILY M EM BER.

5 . THE COM PLETED CLAIM FORM SHOULD BE RETURNED TO:

POM CO

P.O. BOX 6329

SYRA CUSE, NY 13217

TOLL FREE NUMBER 1-800-234-9862

IM PORTA NT REM INDER:

PLEA SE BE SURE THE EM PLOYEE'S SOCIA L SECURITY NUM BER HA S BEEN PROVIDED.

"ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD FILES A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACTUAL MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME"

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