Get 128b Bom Comm. Ins. Pat Payor Info. Form Gen. 3-18-09

Filling out the 128b BOM Comm. Ins. PAT PAYOR INFO. FORM Gen. 3-18-09 is essential for ensuring that your insurance information is accurately recorded and processed. This guide will provide clear, step-by-step instructions to assist you in completing the form online, making the process more manageable and efficient.

Follow the steps to successfully fill out the form online.

1. Select the ‘Get Form’ button to access the form and open it for editing.
2. Begin by entering the patient's full legal name, including their last name, first name, and middle initial, as it appears on the insurance card.
3. Provide the patient's address, including street, apartment number, city, state, and zip code.
4. Fill in the patient's contact numbers, including home, mobile, work, and emergency contacts.
5. Indicate the patient's sex and date of birth, and include their Social Security number and legal photo ID number.
6. List the condition to be treated in physical therapy, along with the date this condition began.
7. Answer questions regarding auto accidents and previous surgeries related to the condition.
8. Provide information about the referring doctor, including their name and office phone number.
9. If insurance is being filed, check the appropriate box indicating whether the patient is the insured or provide details for the insured person, if different.
10. Complete the employer information if the insured person's employer is the source of benefits.
11. Enter the primary and secondary insurance company information, including policy details and the claims mailing address.
12. Document any medications the patient is taking, either by providing a separate list or filling in the required information directly.
13. Initial the payment authorization statements to confirm acceptance of the terms.
14. Have the patient or their legal representative sign and date the form in the appropriate section.

Complete your documents online to ensure efficient management of your insurance information.