Get Key Benefit Administrator Request Form

Submit To BENEFIT REQUEST FORM TYPE OR PRINT Key Benefit Administrators Inc. P. O. Box 2050 Fort Mill SC 27916-2050 PATIENT INFORMATION TO BE COMPLETED BY EMPLOYEE 1. PATIENT S NAME First name middle initial last name FULL TIME STUDENT YES NO IF YES WHERE 4. PATIENT S ADDRESS if different from employee 9. OTHER HEALTH INSURANCE COVERAGE NO If yes Enter Name of Policyholder and Plan Name and Address and Policy or Medical Assistance Number 2. PATIENT S DATE OF BIRTH 3. EMPLOYEE S NAME AND ADDRESS 5. PATIENT S SEX MALE FEMALE 7. PATIENT S RELATIONSHIP TO INSURED SELF SPOUSE CHILD OTHER 10. WAS CONDITION RELATED TO 6. EMPLOYEE S SOC. SEC. NO. A. PATIENT S EMPLOYMENT date20and time description how where 8. GROUP NAME e*g* employer 11. IF AN ACCIDENT AM PM B AN ACCIDENT 12. PATIENT S OR AUTHORIZED PERSON S SIGNATURE 13. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED I authorize the Release of any Medical Information Necessary to Process this request. PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW* SIGNED DATE SIGNED Employee or Authorized Person 14. DATE OF 17. DATE PATIENT ABLE TO RETURN TO WORK ILLNESS FIRST SYMPTOM OR INJURY ACCIDENT OR PREGNANCY LMP 18. DATES OF TOTAL DISABILITY FROM 19. NAME OF REFERRING PHYSICIAN 15. DATE FIRST CONSULTED YOU FOR THIS CONDITION 16. HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS DATES OF PARTIAL DISABILITY THROUGH 20. FOR SERVICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION ADMITTED 21. NAME ADDRESS OF FACILITY WHERE SERVICES RENDERED if other than home or office DISCHARGED 22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE CHARGES 23. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATED TO PROCEDURE IN COLUMN D BY REFERENCE TO NUMBERS 1 2 3 ETC. OR DX CODE OF SERVICE PLACE C FULLY DESCRIBE PROCEDURES MEDICAL SERVICES OR SUPPLIES FURNISHED FOR EACH DATE GIVEN PROCEDURE CODE IDENTIFY 25. SIGNATURE OF PHYSICIAN OR SUPPLIER EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES D DIAGNOSIS CODE F E 27. TOTAL CHARGE 30. YOUR SOC. SEC. NO. AMOUNT PAID BALANCE DUE 31. PHYSICIAN S OR SUPPLIER S NAME ADDRESS ZIP CODE PHONE NO. 32. YOUR PATIENT S ACCOUNT NO. PLACE OF SERVICE CODES 1- IH -INPATIENT HOSPITAL 2- OH -OUTPATIENT HOSPITAL 3- O -DOCTOR S OFFICE 33. YOUR EMPLOYER ID NO 4- H -PATIENT S HOME 5- DAYCARE FACILITY PSY 6- NIGHT CARE FACILITY PSY PLEASE USE CURRENT PROCEDURAL TERMINOLOGY CODES FOR SURGERY 7- NH -NURSING HOME 8- SNF -SKILLED NURSING FACILITY 9AMBULANCE O- OL -OTHER LOCATIONS A- IL -INDEPENDENT LABORATORY B- OTHER MEDICAL/SURGICAL FACILITY. PATIENT S NAME First name middle initial last name FULL TIME STUDENT YES NO IF YES WHERE 4. PATIENT S ADDRESS if different from employee 9. OTHER HEALTH INSURANCE COVERAGE NO If yes Enter Name of Policyholder and Plan Name and Address and Policy or Medical Assistance Number 2. OTHER HEALTH INSURANCE COVERAGE NO If yes Enter Name of Policyholder and Plan Name and Address and Policy or Medical Assistance Number 2. PATIENT S DATE OF BIRTH 3. EMPLOYEE S NAME AND ADDRESS 5. PATIENT S SEX MALE FEMALE 7. PATIENT S RELATIONSHIP TO INSURED SELF SPOUSE CHILD OTHER 10. .