Get Coordination Of Benefits Form - City Of Colorado Springs

Filling out the Coordination Of Benefits Form is an essential step for policyholders of the City of Colorado Springs to ensure proper processing of medical claims. This guide provides clear, step-by-step instructions to help you complete the form online with confidence.

Follow the steps to complete your form accurately and efficiently.

1. Click the ‘Get Form’ button to access the Coordination Of Benefits Form. This will open the document in the online editor for you to fill it out.
2. Begin by entering the print policyholder's or employee's name and their identification number in the designated fields. Make sure to include the date of birth for accurate identification.
3. Respond to the first question regarding whether you, your spouse, or any eligible dependent children have had other medical insurance coverage in the last 12 months. Choose ‘Yes’ or ‘No’ and, if applicable, provide the termination date of any other insurance.
4. For question two, indicate if any dependents currently have other insurance coverage in addition to the City of Colorado Springs policy. If yes, list the dependent’s name, date of birth, social security number, and any relevant Medicare HCIN number.
5. Respond to the question about Medicare coverage for you and your enrolled dependents. If applicable, provide the name(s), type(s) of coverage (Parts A, B, C, D, or ESRD), social security numbers, and effective dates.
6. If there are any other medical insurance policies, fill out the details in the provided sections. Include the policyholder’s name, date of birth, policy number, effective date, and the names and social security numbers of all other dependents under that policy.
7. For question five related to divorced or separated parents of dependent children, answer whether parents have joint custody and provide necessary custody details. Include the name and address of the parent with primary custody if applicable, and confirm if a court order dictates the primary insurance.
8. Review all the completed sections for accuracy. Sign and date the form in the designated area and print your name.
9. After filling out the form completely, save your changes. You may then download, print, or share the document as necessary for submission.

Complete your Coordination Of Benefits Form online today to ensure timely processing of your medical claims.