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For use with the Humana Family of Health Insurance and Health Plan Companies Health Benefits Claim Form To Be Completed By Member 1. Complete ALL information requested below. 2. Use separate form for each family member and for each accident or illness. 3. Enclose ORIGINAL itemized bills. Please keep a copy for your records. Cancelled checks ARE NOT acceptable. 4. ASSIGNMENT If you wish benefits to be paid directly to the physician or provider of service sign the Direct Payment block below. NOTE Benefits for hospital confinement will be paid directly to the hospital* 5. Mail completed form to the address on the back of your insurance card. INSTRUCTIONS 1. Employee/Member Name Last First M. I. 2. Member ID 11 characters 3. Group Number 5. Group Name 8. Patient s Name Last 10. Service Dates From To Place of Service 9. Patient s Relationship to Employee CPT Code/Service Description Place of Service Codes 11- Doctor s Office 12- Patient s Home 20- Urgent Care 21- Inpatient Hospital 22- Outpatient Hospital 23- Emergency Room 31- Skilled Nursing Facility 32- Nursing Home 33- Other Medical/Surgical Facility 41- Ambulance 52- Psychiatric Facility 55- Residential Treatment Center 72- Rural Health Clinic 81- Independent Laboratory 99- Other Locations RELEASE OF INFORMATION I authorize the release of any medical information necessary to process this claim* I understand that as permitted by law to the extent of benefits paid under this claim the Plan acquires all rights of recovery I may have against other parties considered responsible for these expenses. 12. Patient or Authorized Person s Signature Date 7. Patient Birth Date Diagnosis Code Unit Charges Days or Total Charges Physician Supplier and/or Group Name Address Zip Code Telephone No* and Tax ID No* If Payment Is To Be Sent Directly To Provider I hereby authorize payment directly to the provider of services and I understand that I am financially responsible for the hospital medical or physician charges not covered by this authorization* 13. Employee s Signature Any person who knowingly and with intent to defraud any insurance company and files a statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance act which is a crime. Complete ALL information requested below. 2. Use separate form for each family member and for each accident or illness. 3. Enclose ORIGINAL itemized bills. Please keep a copy for your records. Cancelled checks ARE NOT acceptable. 3. Enclose ORIGINAL itemized bills. Please keep a copy for your records. Cancelled checks ARE NOT acceptable. 4. ASSIGNMENT If you wish benefits to be paid directly to the physician or provider of service sign the Direct Payment block below. 4. ASSIGNMENT If you wish benefits to be paid directly to the physician or provider of service sign the Direct Payment block below. NOTE Benefits for hospital confinement will be paid directly to the hospital* 5. Mail completed form to the address on the back of your insurance card. .

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