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Coordination of Benefits Form

Only complete the questions that follow if you have received a letter from Hill Physicians Medical Group that specifically asks you to provide this information. If you are covered by more than one group health plan, payment of benefits may be coordinated between the health plans to ensure you receive all appropriate benefits under your plan.

Please use this secure form to submit changes.

All information submitted through this form is confidential and secure. For more information, read Website Privacy.

• All fields with a red dot are required

Member name (last, first): •

Insurance Coverage #1
Subscriber name (last, first): •
Health plan: •
Member ID: •
Date of birth: (mm/dd/yyyy)•
Group ID: •
Employer name: •
Family members covered under this health plan: list their name, date of birth, and subscriber relationship: •

Insurance Coverage #2
Subscriber name (last, first): •
Health plan: •
Member ID: •
Date of birth: (mm/dd/yyyy)•
Group ID: •
Employer name: •
Family members covered under this health plan: list their name, date of birth, and subscriber relationship: •
If one or more of your dependent children is covered under two health plans, which parent has legal custody and/or financial responsibility? •
Dependent name: •
Date legal custody was awarded: •

Medicare
Your Medicare ID: •
 
Medicare Part A (Hospital)? •
 
Medicare Part B
(Physician Services)?		 •
 
Medicare Part A effective
date (from card):		 •
 
Medicare Part B effective
date (from card): 		•
 
I am receiving Medicare
because I am 65 or older: 		•
 
I am receiving Medicare
due to a disability:		 •
 
I am receiving Medicare
because of kidney disease:		 •
 
First date of dialysis: •
 
I am covered under a group health plan because I am working •
 
I am covered under the group health plan of my working spouse: •
 
If yes, that employer has:

•
Spouse's Medicare ID: •
 
Medicare Part A (Hospital)? •
 
Medicare Part B
(Physician Services)?		 •
 
Medicare Part A, effective
date as shown on the card:		 •
 
Medicare Part B, effective
date as shown on the card:		 •
 
I am receiving Medicare
because I am 65 or older: 		•
 
I am receiving Medicare
due to a disability:		 •
 
I am receiving Medicare
because of kidney disease:		 •
 
If yes, what was the first
date of dialysis treatment:		 •
 
I am covered under a group health plan because I am working: •
 
I am covered under the group health plan of my working spouse: •
 
If yes, that employer has:

•
Please use the space provided for any comments you may have: •

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