Fill and Sign the Form Flood Insurance Application 2010

COMMERCIAL MEMBER CLAIM This form may be used for Health Net and Health Net Life Insurance Company products or products offered by your employer group. Complete the claim form as indicated below. For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement STEP 1. in state prison. Fill out a separate form for each member submitting bills for covered services. To avoid any delay be sure to answer each question completely. ASK YOUR PHYSICIAN TO COMPLETE THE BACK OF THIS FORM. SUBMIT TO: HEALTH NET COMMERCIAL CLAIMS P.O. BOX 14702 LEXINGTON, KY 40512 PLEASE ATTACH FULLY ITEMIZED BILLS AND / OR PROOF OF PAYMENT. SUBSCRIBER INFORMATION - Employee Social Security # must be indicated to assure prompt processing of this request. SUBSCRIBER NAME LAST FIRST MI HOME ADDRESS SUBSCRIBER SOCIAL SECURITY # DATE OF BIRTH (Mo / Day / Yr) CITY STATE ZIP IS THIS A NEW ADDRESS? ❑ Yes GROUP # ❑ Married ❑ Single ❑ Divorced ❑ Widowed MARITAL STATUS ❑ No PATIENT INFORMATION CLAIM IS FOR IF SON / DAUGHTER, IS HE OR SHE MARRIED? ❑ Self ❑ Spouse ❑ Daughter ❑ Son ❑ Other (specify) _______________ ❑ Yes ❑ No SPOUSE / DEPENDENT INFORMATION - Complete below if claim is for employee’s spouse or dependent. NAME LAST FIRST MI DATE OF BIRTH Is your child dependent upon you for at least half of his or her maintenance and support? ......................................................... ❑ Yes Is he or she a full-time student? .................................................................................................................................................... ❑ Yes IF DEPENDENT IS A STUDENT, GIVE NAME AND LOCATION OF HIS OR HER SCHOOL Did you obtain services from a Health Net network physician? ❑ No ❑ No NUMBER OF UNITS ❑ Yes HAVE YOU OR YOUR PHYSICIAN RECEIVED PRECERTIFICATION FOR ALL OR PART OF THE CLAIM? ❑ No ❑ Yes ❑ No Approx Date ______________ ILLNESS / INJURY / PREGNANCY INFORMATION NAME OF REFERRING PHYSICIAN DID YOU SELECT THIS PHYSICIAN FROM YOUR NETWORK DIRECTORY? (FOR SELECT, OPTION OR ELECT) IS THIS PHYSICIAN AFFILIATED WITH YOUR PMG / IPA? (FOR SELECT, OPTION OR ELECT) IS THE INJURY OR ILLNESS WORK RELATED? ❑ Yes DATE ACCIDENT OR ILLNESS OCCURRED ❑ No If yes, employer’s name ❑ Yes ❑ Yes ❑ No ❑ No DO YOU BELIEVE YOU ARE COVERED BY OTHER MEDICAL INSURANCE PREVIOUS TO HEALTH NET FOR THIS CONDITION? ❑ Yes ❑ No If yes, give name(s) OTHER HEALTH INSURANCE INFORMATION IS PATIENT PRESENTLY COVERED BY OTHER MEDICAL INSURANCE, INCLUDING MEDICARE? ❑ Yes FOR MEDICARE, INDICATE PARTS MEMBER IS ENROLLED IN ❑ No ❑ Part A ❑ Part B NAME OF OTHER INSURANCE COMPANY POLICY # EFFECTIVE DATE INSURANCE COMPANY ADDRESS CITY STATE NAME OF INSURED POLICYHOLDER SOCIAL SECURITY # DATE OF BIRTH EMPLOYER NAME EMPLOYER ADDRESS CITY ZIP STATE ZIP AUTHORIZATION TO OBTAIN AND RELEASE MEDICAL INFORMATION I hereby authorize any physician, health care practitioner, hospital, clinic or other medically related facility to furnish to Health Net, its agents, designees or representatives, any and all information pertaining to medical treatment for purposes of reviewing, investigating or evaluating applications or claims. I also authorize Health Net, its agents, designees or representatives to disclose to a hospital or health care service plan, insurer or self-insurer any such medical information obtained if such disclosure is necessary to allow the processing of any claim. If my coverage is under a Group Benefit Agreement held by my employer, an association, trust fund, union or similar entity, this authorization also permits disclosure to them to the extent necessary for utilization review or financial audit purposes. This authorization shall become effective immediately and shall remain in effect as long as Health Net is asked to process claims under my coverage. A photostatic copy of this authorization shall be considered as effective and valid as the original. I hereby certify that the above statements are correct. SIGNATURE OF EMPLOYEE NAME OF PERSON PREPARING FORM (Please print) DATE X 13414 (11/02) (Physician Statement on Reverse) STEP 2. PHYSICIAN STATEMENT: PLEASE HAVE YOUR PHYSICIAN COMPLETE THE FOLLOWING OR ATTACH AN ITEMIZED BILL, MAKING SURE ALL INFORMATION IS ADDRESSED. PATIENT INFORMATION (To be completed by the patient) 1. PATIENT NAME LAST FIRST 3. ASSIGNMENT OF MEDICAL BENEFITS 2. RELEASE OF MEDICAL INFORMATION I authorize the release of any medical information necessary to process this claim. SIGNATURE OF PATIENT (parent or guardian if patient is a minor) MI I authorize payment of medical benefits to the undersigned physician or supplier for services described below. This authorization is invalid unless the tax ID # of the provider is given under # 24 below. DATE SIGNATURE OF INSURED OR AUTHORIZED PERSON X DATE X PHYSICIAN OR SUPPLIER INFORMATION 4. DATE OF ILLNESS (first symptoms), INJURY (accident), OR PREGNANCY (LMP) 7. DATE PATIENT ABLE TO RETURN TO WORK 5. DATE YOU WERE FIRST CONSULTED FOR THIS CONDITION 8. DATES OF TOTAL DISABILITY From Through 6. HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS? ❑ YES ❑ NO If yes, date(s) 9. DATES OF PARTIAL DISABILITY 10. NAME OF REFERRING PHYSICIAN From Through 11. HOSPITALIZATION DATES FOR RELATED SERVICES 12. NAME AND ADDRESS OF FACILITY WHERE SERVICES RENDERED (if other than home or office) 13. LABORATORY WORK OUTSIDE YOUR OFFICE Admitted Discharged ❑ None ❑ Yes Charges 14. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate diagnosis to procedure in column D by reference to number 1, 2, 3 or 4 or DX code. Please give CPT-4 procedure code in C and ICD-9 in D below. 1. 2. 3. 4. B* D C – PROCEDURES, MEDICAL SERVICES OR SUPPLIES FURNISHED A DIAGNOSIS DATES OF PLACE OF PROCEDURE CODE DESCRIPTION (Explain unusual services or circumstances.) CODE SERVICE (Identify) SERVICE 15. TOTAL CHARGE *PLACE OF SERVICE CODES 1 2 3 4 H OH O H - Inpatient Hospital - Outpatient Hospital - Doctor Office - Patient Home E CHARGES 5 6 7 8 - Day Care Facility (Psy) - Night Care Facility (Psy) NH - Nursing Home SNF - Skilled Nursing Facility 18. SIGNATURE OF PHYSICIAN OR SUPPLIER 9 O A B - Ambulance OL - Other Location IL - Independent Laboratory - Other Medical Surgical Facility X 19. ACCEPT ASSIGNMENT? (If yes, tax ID # must be given below) ❑ YES ❑ NO 21. DATE 16. AMOUNT PAID 17. BALANCE DUE 20. PHYSICIAN OR SUPPLIER NAME, ADDRESS, ZIP CODE AND TELEPHONE # 22. PHYSICIAN SOCIAL SECURITY # 23. YOUR PATIENT ACCOUNT # F (INTERNAL USE) 24. PHYSICIAN TAX ID # LICENSE #