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Coordination of Benefits


* Required Fields
 

*Patient Name:
*Enrollee Number:
 

Other Coverage Information

Name of Policy Holder on Other Insurance:
DOB of Policy Holder on Other Insurance:
Relationship to Blue Cross of Idaho Enrollee:
*Name of Insurance Plan:
Area Code and Phone Number:
Location You Send Your Claims To:
Address:
City:
State:
Zip:
Identification Number of Other Plan:

Medicare Information

Name of Person Covered:
Medicare Number:
Is Person Covered under Medicare Part A (Hospital Services)?
Effective Date:
Is Person Covered under Medicare Part B (Physician Services)?
Effective Date:
Is Person Covered under Disability Medicare?
Effective Date:
Is Person Covered under Medicare Part D (Prescription Services)?
Effective Date:

*Contact Name:
*Contact Area Code and Phone Number:
*Contact Email:
*Please type Contact Email again for verification:
Comments

Any other significant information regarding Coordination of Benefits please note below: