Get Coordination Of Benefits Form - Emi Health

Filling out the Coordination Of Benefits Form - EMI Health online can be a straightforward process when you have clear guidance. This guide will walk you through each section of the form to ensure you provide all the necessary information for a successful submission.

Follow the steps to accurately complete your form.

1. Press the ‘Get Form’ button to access the Coordination Of Benefits Form - EMI Health and open it in your preferred online editing tool.
2. Begin by entering your member or subscriber information. This includes your group number, member ID, name (first and last), street address, city, state, and zip code. Make sure all information is accurate to avoid delays in processing.
3. For the patient information section, fill in the patient’s name, date of birth, sex, and their relationship to the plan member. Choose from the provided options such as self, spouse, eligible child, or dependent student.
4. Complete the pharmacy information section by providing the name and address of the pharmacy, including the city, state, zip code, and a contact telephone number. Indicate whether this is an on-site nursing home pharmacy.
5. Next, read and complete the acknowledgment section. This part requires a signature from either the pharmacist or representative, certifying the accuracy of the information provided.
6. Collect and tape all claim receipts or itemized bills on the designated area on the back of the form. Ensure that the receipts contain all required information as listed in the instructions.
7. In the Coordination of Benefits section, mark the appropriate box if another health plan has paid a portion of the claim. Provide any additional documents required as indicated.
8. Review the form for completeness and accuracy, ensuring that all necessary sections are filled out properly.
9. Finally, save your changes, download, print, or share the completed form as needed, and return it along with your receipts to the specified address.

Complete your Coordination Of Benefits Form - EMI Health online today for efficient processing of your claims.