Get Third Party Liability - Cobb & Douglas Public Health

Filling out the Third Party Liability form for Cobb & Douglas Public Health is a crucial step in providing necessary information regarding health insurance coverage. This guide will help users navigate the online session and ensure that all required details are accurately submitted.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by entering the case name and case number at the top of the form. This information is essential for identification purposes.
3. Provide your current address, social security number, and phone number in the designated fields to ensure proper communication.
4. Indicate the type of case you are submitting by checking all applicable options such as 'initial application', 'HIPP referral', 'special needs trust', 'change', or 'cancellation'.
5. If applicable, enter the effective date of any change or cancellation in the specified format.
6. Answer the questions regarding the presence of private, group, or government health insurance that pays for medical care, excluding Medicare or Medicaid. Check 'yes' or 'no' accordingly.
7. List the names of the covered individuals in your household along with their Medicaid ID, if applicable.
8. If applicable, provide details about any pregnancy status by checking 'yes' or 'no' and entering the relevant name and date of delivery.
9. Attach required documentation such as a copy of insurance cards/policies and any applicable special needs trust (SNT) documentation.
10. Disclose any chronic medical conditions among the listed persons by checking 'yes' or 'no' and filling in the name and condition if applicable.
11. Complete the insurance company details including name, telephone number, address, and policy-related information.
12. Review and circle the types of coverage that apply from the list provided on the form.
13. Sign and date the authorization section, certifying that all information is correct, and assign rights to the Department of Community Health as required.
14. After completing all sections, save your changes, download, print, or share the filled-out form as necessary.

Complete your forms online today to ensure timely processing and support.