Fillable Coordination of Benefits Questionnaire (Blue Cross and Blue Shield of Texas)

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Coordination of Benefits Questionnaire (Blue Cross and Blue Shield of Texas)

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Coordination of Benefits Questionnaire
10-06 Page 1
BCBS POLICYHOLDER NAME: ___________________________
BCBS
GROUP #: ___________________________
BCBS
MEMBER ID #: _________ __________________
Your Blue Cross Blue Shield contract contains a Coordination of Benefits (COB) provision. This form is
required by Blue Cross Blue Shield in order for us to process your claims accurately. If you have any
additional questions regarding this questionnaire or if the information below changes, please call the number
found on the back of the identification card. We appreciate your prompt reply.
OTHER INSURANCE:
Are you or any other member of this Blue Cross Blue Shield policy covered by another medical or dental
insurance policy or any other Blue Cross Blue Shield policy?
No If No, please complete Section D, print, sign, date and return this questionnaire to Blue Cross and Blue
Shield of Texas, P.O. Box 660044, Dallas, TX 75266-0044, indicating "No other insurance."
Yes If Yes, please complete all the fields below that pertain to the member(s) that has the other
Coverage, print and return to:
Blue Cross and Blue Shield of Texas, P.O. Box 660044, Dallas, TX 75266-0044,
Section A If this does not apply, skip to Section B.
Check those that apply: Other Health Insurance Other Dental Insurance
What type of policy is this?
Group Individual Policy Student Policy Medicare Supplemental
Other Insurance Carrier’s Name: ________________________________________
Address: ______________________________________________
City, State, Zip: _________________________________________
Phone Number: _______________________________
Dependent(s) listed on the other insurance: Effective or Cancel Date, if different from policyholder:
___________________________________________ ____/____/_____
___________________________________________ ____/____/_____
___________________________________________ ____/____/_____
Other Insurance Policyholder’s Name: _____________________________________
Policyholder’s Date of Birth: ____/____/______ ID # _____________
Effective Date of Other Insurance: ____/____/_____ If Cancelled, Cancellation Date: ____/____/_____
Is the policyholder:
Actively working for the group Inactive Retired, retirement date: ____/____/______
On COBRA, which began: ____/____/______
Policyholder’s Employer: _____________________________________
Employer’s Address: ________________________________________
City, State, & Zip: ___________________________________________
Coordination of Benefits Questionnaire
10-06 Page 2
Section B If this does not apply, skip to Section C.
MEDICARE INFORMATION
Do the policyholder and/or dependent(s) have Medicare? Yes No
Name of person(s) with Medicare: ____________________________
Medicare Number, including alpha character(s): ________________________
Effective Date of Medicare Part A ____/____/______ Effective date of Medicare Part B: ____/____/______
Effective Date of Medicare Part D ____/____/______
Medicare Entitlement:
Age Disability* End Stage Renal Disease (ESRD)*
* If the reason is for Disability or ESRD, please provide the following:
1
st
Date of Disability: ____/____/______
1
st
Date of Dialysis for ESRD: ____/____/______
Was ESRD started in a facility?
Yes No
Was ESRD started as Self Dialysis or Home Dialysis:
Yes No
Has a transplant been performed?
Yes No
If yes, please provide the date of the transplant. ____/____/______
Section C If this does not apply, skip to Section D.
C
OURT ORDER INFORMATION
Is there a Court Order specifying a person(s) to maintain health coverage for any of your dependent(s)?
No Yes
List the name(s) of the dependent(s) that this applies to. _________________________________________
If yes, who is the person(s) listed to maintain health coverage? ____________________________
What is the relation to the child(ren)? ____________________________
Who has custody of the child(ren) more than 50% of the time? ____________________________
Documentation of the court order may be requested from your Blue Cross Blue Shield plan.
Section D
N
AME(S) OF DEPENDENT(S) ON BCBS POLICY
Name Relationship Date of Birth Sex Social Security # (Optional)
__________________ ____________ ____/____/______ ____ _____-____-_______
__________________ ____________ ____/____/______ ____ _____-____-_______
__________________ ____________ ____/____/______ ____ _____-____-_______
Policyholder Signature: _______________________________________ Date: ____/____/______
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Coordination of Benefits Questionnaire (Blue Cross and Blue Shield of Texas)

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Completed 7 July 2021

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