Pomco Form – Fill Out and Use This PDF

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

F

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?

NO

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

NO

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

NO

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

NO

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

O

-

OFFI C E VI SI TS

L -

LAB

OP - OU TPATI ENT

X

-

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