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Health Insurance Claim Form Instructions
The Health Insurance Claim Form is sometime confusing. The following tips may help:
Complete items 1-13 only
The left side of the form provides information about the patient.
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1
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Mark the box indicating your primary insurance carrier.
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2
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Patient’s full name
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3
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Patient’s date of birth |
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5
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Patient’s complete address |
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6
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Patient’s relationship to insurer |
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8
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Patient’s marital status and employment status |
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9
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If patient carries secondary medical
insurance, fill in items 9a-d; if not, leave blank. |
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10
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This question asks whether this condition is related to employment or auto, or other accident. For psoriasis and other skin conditions, specify NO to each.
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DO NOT FORGET TO SIGN ON LEFT specifying that information provided is correct.
The right side of the form provides information about your insurance.
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1a
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Insurance Subscriber identification or policy number
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4
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Subscriber’s name - person who holds policy may be patient, spouse, or parent
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7
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Subscriber’s address |
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11
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Subscriber’s group number |
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11a
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Subscriber’s date of birth and gender |
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11b
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Subscriber’s employer |
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11c
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Subscriber plan name |
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11d
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If patient carries secondary medical insurance, specify YES and fill in items 9a-d. Otherwise, specify NO.
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| 13 |
SIGN ONLY IF insurance is to reimburse National Biological for your equipment. |
If you are paying in full, and expect to be reimbursed directly, DO NOT SIGN right side.
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