Group Medical Direct Claim Form

Group Medical Direct Claim FormInsured and/or Administered byConnecticut General Life Insurance CompanyCIGNA HealthCareMAIL THIS FORM TO: CIGNA HealthCare Service CenterP.O. Box 188013Chattanooga, TN 37422-8013TELEPHONE: 1-800-251-0669 Toll FreeProvider Section and Instructions on Reverse SideA. EMPLOYEE’S NAME (First, M.I., Last)D. EMPLOYEE’S MAILING ADDRESS (Street, City, State, Zip) and DAYTIME PHONE #F. MARITAL STATUSG. POLICY/ACCOUNT NO.3148040 25489EMPLOYEE INFORMATION: Employee Complete This SectionIS THIS A CHANGEOF ADDRESS?YES NOH. DIVISION/BRANCH OR CLASS/LOCATIONB. DATE OF BIRTH C. SEXE. EMPLOYEE’S SOC. SEC. / IDNO.MFI. EMPLOYERCounty of HaysJ. EMPLOYEE STATUSACTIVEHOURLYRETIREDDATECOBRASALARIEDDISABLEDA. PATIENT’S NAME (First, M.I., Last)E.COMPLETE THIS INFORMATIONIF PATIENT IS AN UNMARRIEDDEPENDENT CHILDPATIENT INFORMATION: Complete Only if Patient is Other Than EmployeeDEPENDENT CHILD IS:EMPLOYED FULL-TIMESTUDENT FULL-TIMEB. RELATIONSHIP TO EMPLOYEEC. DATE OF BIRTHNAME, ADDRESS AND PHONE # OF CHILD’S SCHOOL/EMPLOYERD. SEXMFACCIDENT/OCCUPATIONAL CLAIM INFORMATION:Complete Only if Claim is a Result of an Accident or Occupational Illness/InjuryA. DESCRIPTION OF ACCIDENT OR ILLNESS (How, When, Where)C. DATE OF ACCIDENT OR BEGINNING OF ILLNESSF.D. INJURY DUE TO AUTO ACCIDENTYESNOE.B. ACCIDENT OR ILLNESS DUE TO EMPLOYMENTYESHAVE YOU OR YOUR DEPENDENT, OR WILL YOU OR YOUR DEPENDENT FILECLAIM FOR WORKERS’ COMPENSATION BENEFITS?YES NOARE YOU OR YOUR DEPENDENTS FILING A CLAIM OR LAWSUIT AGAINST A THIRD PARTY IN ORDER TO RECOVER THE COST OF EXPENSES INCURRED AS A RESULT OF THISACCIDENT OR ILLNESS? YES NONOA.SPOUSE EMPLOYEDYESNOC. SPOUSE’S SOC. SEC. / IDNO.FAMILY/OTHER COVERAGE INFORMATION:Complete Only if Claim is for a Dependent and/or Other Coverage is in EffectIF NO, HAS SPOUSE BEEN EMPLOYEDDURING LAST 12 MONTHS?YES NOB. NAME OF SPOUSED. NAME, ADDRESS AND PHONE # OF SPOUSE’S EMPLOYERSPOUSE’S DATE OF BIRTHE.IS THE PATIENT COVERED UNDER ANOTHER GROUP INSURANCE OR GOVERNMENT PLAN SUCH AS MEDICARE, AN HMO PLAN OR AUTOMOBILE MANDATORYNO-FAULT COVERAGE WHICH WILL ALSO COVER ANY OF THE MEDICAL EXPENSES OR DISABILITY LOSSES OF THIS CLAIM?YES NOIF YES, GIVE NAME AND ADDRESS OF INSURANCE COMPANY, ORGANIZATION, OR HMO PROVIDING BENEFITS.NAME & ADDRESSPOLICY NUMBERA.EMPLOYEE’S/PATIENT’S SIGNATURE AND RELEASE: Employee Must Sign all ClaimsAUTHORIZATION TO RELEASE INFORMATION- I authorize any Health Care Provider, Insurance Company, Employer, Person or Organization to release anyinformation regarding the medical, dental, mental, alcohol or drug abuse history, treatment, or benefits payable, including disability or employment relatedinformation, to any CIGNA company, the Plan Administrator, or their authorized agents for the purpose of validating and determining benefits payable. I willreceive a copy of this authorization upon request. This authorization or a copy shall be valid for one year from the date of signature.PATIENT’S SIGNATURE (Parent or Guardian if Claim is on a Minor)DATENOTE:If you wish your benefits paid directly to the physician or provider of service, sign in box B, below. Benefits will be paid directly to the hospital for a hospital confinement.B.C.PAYMENT AUTHORIZATION - I authorize payment directly to thoseHealth Care Providers described below, and/or as indicated on theenclosed bills, of Medical Benefits otherwise payable to me, forservices rendered by them.CERTIFICATIONI certify that this information is true and correct.IF YES, EMPLOYEE’S SIGNATUREEMPLOYEE’S SIGNATUREDATEDATECL503919 Rev. 4-98CG/Equicor Direct/Fully Insured CMP/ASO Medical Base

Diagnosis or Nature of Illness or Injury - Relate diagnosis to procedure inColumn D by reference to numbers 1, 2, 3, etc. or ICD-9 Code.PHYSICIAN or PROVIDER: Complete This SectionDATE OF ILLNESS (FIRST SYMPTOM) ORINJURY (ACCIDENT) OR PREGNANCY (LMP)DATE FIRST CONSULTEDFOR THIS CONDITIONHOSPITAL CONFINEMENT DATES1.2.3.4.DATE ABLE TO RETURN TO WORK TOTAL DISABILITY DATESFROMTONAME AND ADDRESS OF REFERRING PHYSICIAN OR OTHER SOURCEFROMTOPARTIAL DISABILITY DATESFROMTOA. B. PLACEDATE OF SERVICE OF SERVICE*C. FULLY DESCRIBE PROCEDURES, MEDICAL SERVICES OR SUPPLIES FURNISHED FOR EACH DATE GIVENPROCEDURE CODE(CPT-4: )(Explain unusual services or circumstances)D. ICD-9DIAGNOSISCODEE.CHARGESYOUR PATIENT’S ACCOUNT NO.PHYSICIAN’S OR PROVIDER’S TAX IDENTIFICA-TION NUMBER OR SOCIAL SECURITY NUMBERTO BE USED FOR TAX REPORTING.PHYSICIAN OR PROVIDER’S NAME AND ADDRESSTOTAL CHARGETAX I.D. #AMOUNT PAIDI certify that the foregoing information is true and correct andthat the charges are the actual charges to the insured.*1. (IH)2. (OH)3. (O)---Inpatient HospitalOutpatient HospitalDoctor’s OfficeSOC. SEC. #4. (H)5. (PSY)6. (PSY)- Patient’s Home- Day Care Facility- Night Care FacilityPHYSICIAN’S OR PROVIDER’S TELEPHONE NUMBER( )PHYSICIAN’S OR PROVIDER’S SIGNATURE7.8.9.(NH) -(SNF) -AmbulanceNursing HomeSkilled Nursing FacilityO.A.B.DATE(OL) -(IL) -Other Medical FacilityBALANCE DUEOther LocationsIndependent LaboratoryINSTRUCTIONS FOR FILING A CLAIMAny person who knowingly and with intent to defraud any insurance company or other person files a statement containingany materially false information, or conceals, for the purpose of misleading, information concerning any fact materialthereto, commits a fraudulent insurance act which is a crime.1.2.3.4.5...YOU SHOULD SUBMIT YOUR CLAIMS MONTHLY OR WHEN YOU HAVE BILLS TOTALING MORE THAN $200.00;BUT YOU MUST USE A SEPARATE CLAIM FORM FOR EACH MEMBER OF THE FAMILY.IMPORTANTA completed claim form must be included with each submission for each member of the family for each separate accident orillness.Your claim cannot be processed without your Social Security Number (Employee Section, Block E).You must sign and date your claim form (Employee’s / Patient’s Signature and Release Section).ATTENDING PHYSICIAN OR PROVIDER INFORMATION SECTION SHOULD BE COMPLETED FOR . . .Surgery Doctor’s Visits Mental Illness Expenses Hospital ConfinementBe certain to include procedure code and ICD-9 Diagnosis Code (Physician or Provider Section, blocks C and D).IF ENCLOSING ITEMIZED BILLS, THEY MUST INCLUDE:ALL BILLS..Employee NamePatient NameType of ServiceDate of ServiceDiagnosisCharge for ServiceBe certain to include Physician or Tax Identification number.Bills will not be returned to you - make copies for your records.Receipts, balance due statements and cancelled checks are not acceptable.Patient NamePhysician NamePrescription NumberADDITIONAL INFORMATIONSave your Explanation of Benefits - duplicate vouchers are not available.Second Opinion Surgical Program - Call your benefits counselor for details.MAILING INSTRUCTIONSSend your completed claim form and itemized bills to the address indicated on the front of this form.DRUG BILLS(Please tape to an 8 1/2" x 11" piece of paper)Prescription DateDrug NameCharge284107Cat. #503919 (Back) Rev. 4-98