Coordination of Benefits
If you have insurance coverage with another health plan or Medicare, you must inform us to coordinate your
benefits and share the cost of your health care. In order to process claims correctly, please complete and
return this form as soon as possible, as future claims will not be processed if this form is not received.
Member Name: ______________________________ Address: ____________________________________
City: ______________________________________ State: ______________ Zip: ______________________
Member ID Number:_______________________________________________________________________
Type of Health Coverage
While covered by Sanford Health Plan, have you or any of your family members been covered by another:
Health Plan (including Medicare) □ Yes □ No
Dental Plan □ Yes □ No
Prescription Plan □ Yes □ No
If you checked “Yes” to any box above, please complete all applicable fields on the form. If you checked “No” in
all the boxes above, please sign and date the form. When complete, return to Sanford Health Plan:
By mail at the address above
By fax at (701) 282-8063
By emailing this form or necessary information to
By contacting Customer Service using the information above.
Other Coverage/Medicare Information
Name of other insurance company:
Effective date of other coverage:
Phone number of other insurance company:
Policyholder’s name with other insurance:
First and last names of members on this policy:
Policyholder’s date of birth with other insurance:
Member ID number:
Medicare ID number:
Medicare Only - Effective date(s):
Part B:
Part C:
Divorce Decree/Child Support Orders/Court Orders
Is there a divorce decree/ child support order /court order that orders one or both parents to provide health
insurance for any covered dependents: □ Yes □ No
If yes, a copy of the divorce decree/ child support order /court order is REQUIRED and will only
be used for claims processing.
Person(s) required to carry health insurance per divorce decree/court order (first and last name(s))
Person with Primary Physical Custody:
Subscriber Signature:
Questions? Please contact Customer Service for assistance.
HP-1395 09/18
Coordination of Benefits
1749 38th Street S.
Fargo ND 58103
Customer Service: (800) 752-5863
NDPERS Customer Service: (800) 499-3416
ND Medicaid Expansion Customer Service: (855) 305-5060