Coordination of Benefits QuestionnairePlease Print Subscribers Name: ________________________________________________ Identification Number _______________________________________
Subscribers Social Security Number: _______________________________ Spouses Social Security Number: ____________________________
In addition to your Blue Cross and Blue Shield coverage, are you, your spouse or dependent children covered by another group health insurance plan or Medicare? Yes If yes, please complete the entire questionnaire No If no, please complete the question below, below, sign and return to us. sign and return to us.
If you had other health insurance coverage which cancelled when your Blue Cross and Blue Shield coverage became effective, please provide Name of carrier or plan __________________________________________________________ and Cancellation Date __________________________
Other Health Insurance:If Multiple Coverage Exists, Please List On A Separate Sheet Of Paper
1. Policy Holders Name: ______________________________________________ Sex: Male Female
2. Policy Holders Social Security Number: _______________________________________________ Date of Birth: ___________________________
3. Name of Employer providing coverage: ________________________________________________ 4. Name of Other Insurance Company: _________________________________________ Policy Number: ________________________________
5. Address of Other Insurance Company: ___________________________________ Phone Number: ____________________________________
6. Effective Date of Policy: __________________________________ Cancellation Date of Policy (If Applicable): _____________________________
7. Policy Covers: Policy Holder Only ____________ Two Persons __________ Family __________
_____________________________________________ _____________________________________________
_____________________________________________ _____________________________________________
_____________________________________________ _____________________________________________
8. Services Covered: A. Hospital Services Yes No D. Major Medical (Out of pocket expenses not otherwise covered) Yes No B. Physician Services Yes No E. Eye or Vision Care Yes No C. Dental Coverage Yes No F. Catastrophic Benefits Only Yes No
Middle InitialLast First
Mo. Day Yr.
Mo. Day Yr.
Mo. Yr.Day Mo. Day Yr.
Name
Name
Name
Relationship to Policy Holder
Relationship to Policy Holder
Relationship to Policy Holder
To be completed for dependents whose natural parents live apart and who provide medical coverage for these dependents. Please indicate relationship to children (natural mother, natural father, step-father). If multiple children, please list on a separate sheet of paper.
Parent WithCustody OfChild(ren)
Parent WithCourt AssignedResponsibilityFor Child(ren)sMedical Expenses
Parents Name Relationship to Child Childs Name Childs Date of Birth
Parents Name Relationship to Child Childs Name Childs Date of Birth
9. Do you or any of your dependents have Medicare? Yes No If Yes, please complete the following:
Subscribers Signature___________________________________ Date _______________ Work Phone Number ____________________
Home Phone Number ____________________
Participants Name Birthdate Medicare Number Hospital (Part A) Medical (Part B) Effective Date Effective Date __________________________________ ______________________ ____________________ _________________________ ________________________
Eligible for Medicare as a result of (check one) DisabilityEnd StageRenal DiseaseAge
Beginning date of renal treatment:_______________________
Yes NoParticipant Actively Employed
Yes NoSpouse Actively EmployedMo. Day Yr.
Registered trademark of the Blue Cross and Blue Shield Association. COB_Questionnaire-IF1-Z9213 (2/18)
SEND FORM TO:
To facilitate a quicker response to your inquiry, please complete this form and attach all relevant claim information (claim, EOMB, operative notes) and send to the proper address below based on the members insurance coverage:
n MD, NCA, BlueChoice: CareFirst BlueCross BlueShield Mail Administrator P.O. Box 14114 Lexington, KY 40512-9881
n FEPFederal Employee Program: Mail Administrator P.O. Box 14113 Lexington, KY 40512-4113
n NASCO and Maryland Care Business: CareFirst BlueCross BlueShield PO Box 14114 Lexington, KY 40512-4114
Copies of this form may be obtained by visiting www.carefirst.com Members & Visitors Forms.
http://www.carefirst.com
Notice of Nondiscrimination and Availability of Language Assistance Services
CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.
CareFirst:
Provides free aid and services to people with disabilities to communicate effectively with us, such as:Qualified sign language interpretersWritten information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:Qualified interpretersInformation written in other languages
If you need these services, please call 855-258-6518.
If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you.
To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator as indicated below. Please do not send payments, claims issues, or other documentation to this office.
Civil Rights Coordinator, Corporate Office of Civil RightsMailing Address P.O. Box 8894 Baltimore, Maryland 21224
Email Address [email protected]
Telephone Number 410-528-7820 Fax Number 410-505-2011
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:
U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.
REV. (12/17)
Foreign Language Assistance Attention (English): This notice contains information about your insurance coverage. It may contain key dates
and you may need to take action by certain deadlines. You have the right to get this information and assistance in
your language at no cost. Members should call the phone number on the back of their member identification card.
All others may call 855-258-6518 and wait through the dialogue until prompted to push 0. When an agent
answers, state the language you need and you will be connected to an interpreter.
(Amharic) -
855-258-6518 0
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tt a fi s fn lti t 0. Ngbt aoj kan b dhn, s d t o f a s so p m gbuf kan.
Ting Vit (Vietnamese) Ch : Thng bo ny cha thng tin v phm vi bo him ca qu v. Thng bo c th
cha nhng ngy quan trng v qu v cn hnh ng trc mt s thi hn nht nh. Qu v c quyn nhn
c thng tin ny v h tr bng ngn ng ca qu v hon ton min ph. Cc thnh vin nn gi s in thoi
mt sau ca th nhn dng. Tt c nhng ngi khc c th gi s 855-258-6518 v ch ht cuc i thoi cho
n khi c nhc nhn phm 0. Khi mt tng i vin tr li, hy nu r ngn ng qu v cn v qu v s c
kt ni vi mt thng dch vin.
Tagalog (Tagalog) Atensyon: Ang abisong ito ay naglalaman ng impormasyon tungkol sa nasasaklawan ng iyong
insurance. Maaari itong maglaman ng mga pinakamahalagang petsa at maaaring kailangan mong gumawa ng
aksyon ayon sa ilang deadline. May karapatan ka na makuha ang impormasyong ito at tulong sa iyong sariling
wika nang walang gastos. Dapat tawagan ng mga Miyembro ang numero ng telepono na nasa likuran ng kanilang
i
