Get Medicare Coordination Of Benefits Form

Completing the Medicare coordination of benefits form online can streamline the process of managing your health care benefits. This guide provides clear and detailed steps to assist you in accurately filling out the form to ensure proper enrollment and coverage coordination.

Follow the steps to complete the form effectively

1. Press the ‘Get Form’ button to acquire the form and open it in your preferred editing tool.
2. Begin by entering the beneficiary’s name in the designated field. Make sure the spelling is correct to avoid any processing delays.
3. Next, input the beneficiary’s health insurance claim (HIC) number in the appropriate section. This number is crucial for identifying benefits.
4. Provide the beneficiary’s current address, ensuring it is complete and accurate to receive any related correspondence.
5. Answer question 1: Indicate whether you are currently receiving benefits from an employer group health plan by selecting ‘YES’ or ‘NO’.
6. For question 2, if you answered ‘YES’ to question 1, specify whether the employer has 20 or more employees by selecting ‘YES’ or ‘NO’.
7. If you answered ‘YES’ or are unsure about the employer size, complete the section with details about the employer group health plan, including the name, address, group name, and policy number.
8. Proceed to question 4: Indicate if you are receiving benefits from the group health plan of a spouse or other family member by selecting ‘YES’ or ‘NO’.
9. Similar to step 6, for question 5, select whether that employer has 20 or more employees.
10. If you answered ‘YES’ or are unsure, fill in the second section with the name, address, group name, and policy number regarding the family member’s employer.
11. In the policy holder section, enter the phone number and relationship to the policy holder, providing essential context.
12. If you are a Medicare patient, ensure to sign in the section provided for authorization of payment and release of medical information.
13. Finally, review all entries for accuracy and completeness. Once confirmed, you can save changes, download, print, or share the completed form.

Complete your Medicare coordination of benefits form online now.