Get and Sign Health Benefits Claim 2018-2021 Form

NUMBER INCLUDE AREA CODE 10. IS PATIENT COVERED UNDER OTHER HEALTH INSURANCE NO YES q IF YES NAME OF OTHER INSURANCE COMPANY NAME OF POLICY HOLDER POLICY OR IDENTIFICATION NUMBER IS PATIENT COVERED UNDER MEDICARE NO IF YES PART A q SPOUSE q CHILD q OTHER q IF THE SUBSCRIBER IS MARRIED IS THE SPOUSE EMPLOYED NO IF YES GIVE THE NAME OF THE SPOUSE S EMPLOYER q YES q q PART B q MEDICARE NUMBER q YES q IF YES NAME OF EMPLOYER IS PATIENT ACTIVELY EMPLOYED NO AS PATIENT S CONDITION DUE TO MEDICAL...