Fillable MEDICAL CLAIM FORM Submit with Primary Insurance EOB

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MEDICAL CLAIM FORM Submit with Primary Insurance EOB

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The MEDICAL CLAIM FORM Submit with Primary Insurance EOB form is 1 page long and contains:

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  • 49 other fields

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MEDICAL CLAIM FORM
Submit with Primary Insurance EOB via fax to 844-595-6272
Date of Service:
Co-pay MemberID:
Co-Pay Group Number:
Section 1: Patient Information (* required information)
First Name* Last Name*
Middle
Name
Address 1*
Address 2
City*
State* Zip*
Gender*
☐
M
☐
F
☐
U
DOB*
Phone
Number*
Best time
to contact
☐
Morning
☐
Afternoon
☐
Evening
Email
Relationship to insured*
☐
☐
☐
Other Dependent
Section 2: Insured Information (* required information only if different than Patient)
First Name* Last Name*
Middle
Name
Address 1*
Address 2
City*
State* Zip*
Gender*
☐
M
☐
F
☐
U
DOB*
Phone
Number*
Section 3: Billing Practice Information (* required information)
Practice Name*
Tax ID* NPI*
Address 1*
Address 2
City*
State* Zip*
Phone* Email*
Fax*
Section 4: Treating Physician/Provider Information (*required information)
First Name* Last Name*
Middle
Name
Specialty Title
NPI*
Section 5: Payee (To Be Mailed to the Address Above)
☐
Patient
☐
Billing Practice
Q CODE / BAR CODE
ENTYVIO is a trademark of Millennium Pharmaceuticals Inc., registered with the U.S. Patent and Trademark Oce,
and is used under license by Takeda Pharmaceuticals America, Inc.
©2018 Takeda Pharmaceuticals U.S.A., Inc.
US-VED-0120v1.0
08/20
Please click here to read the full Prescribing Information, including Medication Guide.
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MEDICAL CLAIM FORM Submit with Primary Insurance EOB

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Completed 15 July 2021

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