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Coordination of Benefits QuestionnairePlease Print Subscribers
Name: ________________________________________________
Identification Number _______________________________________
Subscribers Social Security Number:
_______________________________ Spouses Social Security Number:
____________________________
In addition to your Blue Cross and Blue Shield coverage, are
you, your spouse or dependent children covered by another group
health insurance plan or Medicare? Yes If yes, please complete the
entire questionnaire No If no, please complete the question below,
below, sign and return to us. sign and return to us.
If you had other health insurance coverage which cancelled when
your Blue Cross and Blue Shield coverage became effective, please
provide Name of carrier or plan
__________________________________________________________ and
Cancellation Date __________________________
Other Health Insurance:If Multiple Coverage Exists, Please List
On A Separate Sheet Of Paper
1. Policy Holders Name:
______________________________________________ Sex: Male Female
2. Policy Holders Social Security Number:
_______________________________________________ Date of Birth:
___________________________
3. Name of Employer providing coverage:
________________________________________________ 4. Name of Other
Insurance Company: _________________________________________ Policy
Number: ________________________________
5. Address of Other Insurance Company:
___________________________________ Phone Number:
____________________________________
6. Effective Date of Policy: __________________________________
Cancellation Date of Policy (If Applicable):
_____________________________
7. Policy Covers: Policy Holder Only ____________ Two Persons
__________ Family __________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
8. Services Covered: A. Hospital Services Yes No D. Major
Medical (Out of pocket expenses not otherwise covered) Yes No B.
Physician Services Yes No E. Eye or Vision Care Yes No C. Dental
Coverage Yes No F. Catastrophic Benefits Only Yes No
Middle InitialLast First
Mo. Day Yr.
Mo. Day Yr.
Mo. Yr.Day Mo. Day Yr.
Name
Name
Name
Relationship to Policy Holder
Relationship to Policy Holder
Relationship to Policy Holder
To be completed for dependents whose natural parents live apart
and who provide medical coverage for these dependents. Please
indicate relationship to children (natural mother, natural father,
step-father). If multiple children, please list on a separate sheet
of paper.
Parent WithCustody OfChild(ren)
Parent WithCourt AssignedResponsibilityFor Child(ren)sMedical
Expenses
Parents Name Relationship to Child Childs Name Childs Date of
Birth
Parents Name Relationship to Child Childs Name Childs Date of
Birth
9. Do you or any of your dependents have Medicare? Yes No If
Yes, please complete the following:
Subscribers Signature___________________________________ Date
_______________ Work Phone Number ____________________
Home Phone Number ____________________
Participants Name Birthdate Medicare Number Hospital (Part A)
Medical (Part B) Effective Date Effective Date
__________________________________ ______________________
____________________ _________________________
________________________
Eligible for Medicare as a result of (check one) DisabilityEnd
StageRenal DiseaseAge
Beginning date of renal treatment:_______________________
Yes NoParticipant Actively Employed
Yes NoSpouse Actively EmployedMo. Day Yr.
Registered trademark of the Blue Cross and Blue Shield
Association. COB_Questionnaire-IF1-Z9213 (2/18)
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SEND FORM TO:
To facilitate a quicker response to your inquiry, please
complete this form and attach all relevant claim information
(claim, EOMB, operative notes) and send to the proper address below
based on the members insurance coverage:
n MD, NCA, BlueChoice: CareFirst BlueCross BlueShield Mail
Administrator P.O. Box 14114 Lexington, KY 40512-9881
n FEPFederal Employee Program: Mail Administrator P.O. Box 14113
Lexington, KY 40512-4113
n NASCO and Maryland Care Business: CareFirst BlueCross
BlueShield PO Box 14114 Lexington, KY 40512-4114
Copies of this form may be obtained by visiting
www.carefirst.com Members & Visitors Forms.
http://www.carefirst.com
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Notice of Nondiscrimination and Availability of Language
Assistance Services
CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and
all of their corporate affiliates (CareFirst) comply with
applicable federal civil rights laws and do not discriminate on the
basis of race, color, national origin, age, disability or sex.
CareFirst does not exclude people or treat them differently because
of race, color, national origin, age, disability or sex.
CareFirst:
Provides free aid and services to people with disabilities to
communicate effectively with us, such as:Qualified sign language
interpretersWritten information in other formats (large print,
audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language
is not English, such as:Qualified interpretersInformation written
in other languages
If you need these services, please call 855-258-6518.
If you believe CareFirst has failed to provide these services,
or discriminated in another way, on the basis of race, color,
national origin, age, disability or sex, you can file a grievance
with our CareFirst Civil Rights Coordinator by mail, fax or email.
If you need help filing a grievance, our CareFirst Civil Rights
Coordinator is available to help you.
To file a grievance regarding a violation of federal civil
rights, please contact the Civil Rights Coordinator as indicated
below. Please do not send payments, claims issues, or other
documentation to this office.
Civil Rights Coordinator, Corporate Office of Civil
RightsMailing Address P.O. Box 8894 Baltimore, Maryland 21224
Email Address [email protected]
Telephone Number 410-528-7820 Fax Number 410-505-2011
You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office for Civil Rights
electronically through the Office for Civil Rights Complaint
portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
or by mail or phone at:
U.S. Department of Health and Human Services 200 Independence
Avenue, SW Room 509F, HHH Building Washington, D.C. 20201
800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
CareFirst BlueCross BlueShield is the shared business name of
CareFirst of Maryland, Inc. and Group Hospitalization and Medical
Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization
and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental
Network and First Care, Inc. are independent licensees of the Blue
Cross and Blue Shield Association. In the District of Columbia and
Maryland, CareFirst MedPlus is the business name of First Care,
Inc. In Virginia, CareFirst MedPlus is the business name of First
Care, Inc. of Maryland (used in VA by: First Care, Inc.).
Registered trademark of the Blue Cross and Blue Shield Association.
Registered trademark of CareFirst of Maryland, Inc.
REV. (12/17)
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Foreign Language Assistance Attention (English): This notice
contains information about your insurance coverage. It may contain
key dates
and you may need to take action by certain deadlines. You have
the right to get this information and assistance in
your language at no cost. Members should call the phone number
on the back of their member identification card.
All others may call 855-258-6518 and wait through the dialogue
until prompted to push 0. When an agent
answers, state the language you need and you will be connected
to an interpreter.
(Amharic) -
855-258-6518 0
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o s le n lti
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wn m-gb
gbd pe nmb fn t w lyn kd dnim wn. wn mrn le pe 855-258-6518 k o
s dr npas jrr
tt a fi s fn lti t 0. Ngbt aoj kan b dhn, s d t o f a s so p m
gbuf kan.
Ting Vit (Vietnamese) Ch : Thng bo ny cha thng tin v phm vi bo
him ca qu v. Thng bo c th
cha nhng ngy quan trng v qu v cn hnh ng trc mt s thi hn nht nh.
Qu v c quyn nhn
c thng tin ny v h tr bng ngn ng ca qu v hon ton min ph. Cc thnh
vin nn gi s in thoi
mt sau ca th nhn dng. Tt c nhng ngi khc c th gi s 855-258-6518 v
ch ht cuc i thoi cho
n khi c nhc nhn phm 0. Khi mt tng i vin tr li, hy nu r ngn ng qu
v cn v qu v s c
kt ni vi mt thng dch vin.
Tagalog (Tagalog) Atensyon: Ang abisong ito ay naglalaman ng
impormasyon tungkol sa nasasaklawan ng iyong
insurance. Maaari itong maglaman ng mga pinakamahalagang petsa
at maaaring kailangan mong gumawa ng
aksyon ayon sa ilang deadline. May karapatan ka na makuha ang
impormasyong ito at tulong sa iyong sariling
wika nang walang gastos. Dapat tawagan ng mga Miyembro ang
numero ng telepono na nasa likuran ng kanilang
identification card. Ang lahat ng iba ay maaaring tumawag sa
855-258-6518 at maghintay hanggang sa dulo ng
diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot
ang ahente, sabihin ang wika na kailangan mo
at ikokonekta ka sa isang interpreter.
Espaol (Spanish) Atencin: Este aviso contiene informacin sobre
su cobertura de seguro. Es posible que
incluya fechas clave y que usted tenga que realizar alguna accin
antes de ciertas fechas lmite. Usted tiene
derecho a obtener esta informacin y asistencia en su idioma sin
ningn costo. Los asegurados deben llamar al
nmero de telfono que se encuentra al reverso de su tarjeta de
identificacin. Todos los dems pueden llamar al
855-258-6518 y esperar la grabacin hasta que se les indique que
deben presionar 0. Cuando un agente de seguros
responda, indique el idioma que necesita y se le comunicar con
un intrprete.
(Russian) !
. ,
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855-258-6518 , 0.
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(Hindi) : - 855-258-6518 0 ,
s-w (Bassa) To uu Cao! B nia k a ny e ke m gbo kpa o ni fu
a-fa-tiin ny je dyi. B nia k
ee we j e m ke wa m m ke nyu nyu hw we ea ke zi. m ni kpe m ke b
nia k ke gbo-
kpa-kpa m m dye e ni ii-wuu mu m ke se wii o p. Kpoo ny e m a
fn-na nia e waa
I.D. kaa ein ny. Ny t sein m a na nia k: 855-258-6518, ke m m fo
tee wa ke m gbo c m ke
na ma 0 k dyi paain hw. ju ke ny o dyi m g juin, po wuu m m po
dyi, ke ny o mu o niin
ke ni wuu mu za.
(Bengali) : 855-258-6518 0
: (Urdu )
0 6518-258-855
: . (Farsi ). .
.
. 0 855-258-6518
.
: (Arabic) . .
.
.0 855-258-6518
.
(Traditional Chinese)
855-258-6518
0
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Igbo (Igbo) Nrbama: kwa a nwere ozi gbasara mkpuchi nchekwa onwe
g. nwere ike nwe bch nd d
mkpa, nwere ike me ihe tupu fd bch njedebe. nwere ikike nweta
ozi na enyemaka a nass g na
akwgh gw bla. Nd otu kwesr kp akara ekwent d naz nke kaad
njirimara ha. Nd z niile nwere
ike kp 855-258-6518 wee chere bb ah ruo mgbe amanyere p 0. Mgbe
onye nnchite anya zara, kwuo
ass chr, a ga-ejik g na onye kwa okwu.
Deutsch (German) Achtung: Diese Mitteilung enthlt Informationen
ber Ihren Versicherungsschutz. Sie kann
wichtige Termine beinhalten, und Sie mssen gegebenenfalls
innerhalb bestimmter Fristen reagieren. Sie haben
das Recht, diese Informationen und weitere Untersttzung
kostenlos in Ihrer Sprache zu erhalten. Als Mitglied
verwenden Sie bitte die auf der Rckseite Ihrer Karte angegebene
Telefonnummer. Alle anderen Personen rufen
bitte die Nummer 855-258-6518 an und warten auf die
Aufforderung, die Taste 0 zu drcken. Geben Sie dem
Mitarbeiter die gewnschte Sprache an, damit er Sie mit einem
Dolmetscher verbinden kann.
Franais (French) Attention: cet avis contient des informations
sur votre couverture d'assurance. Des dates
importantes peuvent y figurer et il se peut que vous deviez
entreprendre des dmarches avant certaines chances.
Vous avez le droit d'obtenir gratuitement ces informations et de
l'aide dans votre langue. Les membres doivent
appeler le numro de tlphone figurant l'arrire de leur carte
d'identification. Tous les autres peuvent appeler le
855-258-6518 et, aprs avoir cout le message, appuyer sur le 0
lorsqu'ils seront invits le faire. Lorsqu'un(e)
employ(e) rpondra, indiquez la langue que vous souhaitez et vous
serez mis(e) en relation avec un interprte.
(Korean) : . .
. ID .
855-258-6518 0 .
.
(Navajo)
855-258-6518