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Independence AdministratorsMedical Claim FormSee the back of this form for instructions.Please mail claims to the address on youridentification card.4 – AUTHORIZATION 3 – PATIENT’S CONDITION 2 – OTHER INSURANCE 1 – MEMBER /Member’s name (First, Middle, Last) Identification # Group #Present address - Street q New address City StatePatient’s name (First, Middle, Last) Patient’s relationship to member Sex Birth dateqSelf qSpouse qChild qMqHandicapped dependent qOther qF ____/____/____Does the patient have other health insurance coverage?qYes qNo If YES, complete the rest of Section 2.Policyholder’s name (First, Middle, Last) Birth date Policyholder’s employment statusqActiveqDisabled____/____/____ qRetired qEffective date: ____/____/____Policyholder’s relationship to member Other insurance carrier’s name Identification # Effective dateqSelf qSpouseqChild qOther ____/____/____Type(s) of coverage (Check all that apply.) qHospitalization qMedical-surgical qDental qVision qDrugqMajor medical qOther (Specify.) ________________________________Contract covers qPolicyholder only qPolicyholder and spouse qPolicyholder and child(ren) qFamilyIs the patient entitled to benefits under Medicare Part A or B? qYes qNo If YES, complete the rest of Section 2.Medicare effective date _____/_____/_____ Medicare ID # _________________________Member’s employment status qActive qRetired qDisableda.Describe the conditions for which you are requesting coverage.Type of injury or illness Name of doctor treating injury/illness Date of first symptoms____________________ ________________________________________ _____/_____/_________________________ ________________________________________ _____/_____/_____b.If this claim is the result of an injury, do you intend to file a claim against another individual, business, organization, orinsurer for damages arising from the injury?qYes qNoc.If this claim is the result of an injury, have you retained an attorney to represent you? qYes qNod.Were the services related to a hospitalization? qYes qNo If YES, complete the rest of Question 3d.Admission date _____/_____/_____Discharge date _____/_____/_____Hospital name ______________________________ Admitting physician ______________________________e.Were the expenses due to an accident? qYes qNo If YES, complete the rest of Question 3e.Accident date _____/_____/_____ qWork qAuto qSchool qOther (Specify.) ____________________f. Is this claim for prescription drugs? qYes qNo If YES, complete the rest of Question 3f.Pharmacy name _________________________ Address ____________________________________________I certify that the information provided on this claim form is correct and complete, and that I am claiming benefits actuallyincurred by the named patient. I authorize any hospital, physician, or other provider who participated in the care andtreatment of the patient to release all medical or other information requested for the processing of the claim to IndependenceAdministrators. I hereby agree to reimburse Indenpendence Administrators in full if this claim is paid incorrectly.Any person who knowingly and with intent to defraud any insurance company or other person files an application forinsurance or statement of claim containing any materially false information or conceals, for the purpose of misleading,information concerning any material fact thereto commits a fraudulent insurance act, which is a crime and subjects suchperson to criminal and civil penalties._____________________________________________________________ _______________________ ________________________MEMBER SIGNATURE DATE (AREA CODE) HOME PHONE (AREA CODE) WORKIA-claim-0307©2007 Independence Administrators
