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Health Net Commercial Member Claim Form


Health Net Commercial Member Claim Form
Health Net Commercial Member Claim Form
AUTHORIZATION TO OBTAIN AND RELEASE MEDICAL INFORMATION
X
SIGNATURE OF EMPLOYEE NAME OF PERSON PREPARING FORM (Please print) DATE
(Physician Statement on Reverse)
13414 (11/02)
ILLNESS / INJURY / PREGNANCY INFORMATION
OTHER HEALTH INSURANCE INFORMATION
IS PATIENT PRESENTLY COVERED BY OTHER MEDICAL INSURANCE, INCLUDING MEDICARE FOR MEDICARE, INDICATE PARTS MEMBER IS ENROLLED IN
NAME OF OTHER INSURANCE COMPANY POLICY # EFFECTIVE DATE
INSURANCE COMPANY ADDRESS CITY STATE ZIP
NAME OF INSURED POLICYHOLDER SOCIAL SECURITY # DATE OF BIRTH
EMPLOYER NAME EMPLOYER ADDRESS CITY STATE ZIP
PATIENT INFORMATION
Self Spouse Daughter Son Other (specify) _______________
SPOUSE / DEPENDENT INFORMATION - Complete below if claim is for employee’s spouse or dependent.
NAME LAST FIRST MI DATE OF BIRTH
IF DEPENDENT IS A STUDENT, GIVE NAME AND LOCATION OF HIS OR HER SCHOOL NUMBER OF UNITS
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
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.
Is your child dependent upon you for at least half of his or her maintenance and support ......................................................... Yes No
Is he or she a full-time student .................................................................................................................................................... Yes No
Yes No Part A Part B
SUBSCRIBER NAME LAST FIRST MI SUBSCRIBER SOCIAL SECURITY #
HOME ADDRESS DATE OF BIRTH (Mo / Day / Yr) GROUP #
CITY STATE ZIP IS THIS A NEW ADDRESS MARITAL STATUS
Yes No
If yes, employer’s name
NAME OF REFERRING PHYSICIAN DID YOU SELECT THIS PHYSICIAN FROM YOUR NETWORK DIRECTORY
IS THIS PHYSICIAN AFFILIATED WITH YOUR PMG / IPA IS THE INJURY OR ILLNESS WORK RELATED
DATE ACCIDENT OR ILLNESS OCCURRED DO YOU BELIEVE YOU ARE COVERED BY OTHER MEDICAL INSURANCE PREVIOUS TO HEALTH NET
FOR THIS CONDITION
Yes No
If yes, give name(s)
CLAIM IS FOR IF SON / DAUGHTER, IS HE OR SHE MARRIED
Yes No
HAVE YOU OR YOUR PHYSICIAN RECEIVED PRECERTIFICATION FOR ALL OR PART OF THE CLAIM
Did you obtain services from a Health Net network physician
Yes No
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.
COMMERCIAL MEMBER CLAIM
Married Single
Divorced Widowed Yes No
Yes No Approx Date ______________
(FOR SELECT, OPTION OR ELECT)
Yes No
Yes No
(FOR SELECT, OPTION OR ELECT)
STEP 1.
Health Net Commercial Member Claim Form
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