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AUTHORIZATION TO OBTAIN AND RELEASE MEDICAL INFORMATION
SIGNATURE OF EMPLOYEENAME OF PERSON PREPARING FORM (Please print)DATE
(Physician Statement on Reverse)
ILLNESS / INJURY / PREGNANCY INFORMATION
OTHER HEALTH INSURANCE INFORMATION
IS PATIENT PRESENTLY COVERED BY OTHER MEDICAL INSURANCE, INCLUDING MEDICAREFOR MEDICARE, INDICATE PARTS MEMBER IS ENROLLED IN
NAME OF OTHER INSURANCE COMPANYPOLICY #EFFECTIVE DATE
INSURANCE COMPANY ADDRESSCITYSTATEZIP
NAME OF INSURED POLICYHOLDERSOCIAL SECURITY #DATE OF BIRTH
EMPLOYER NAMEEMPLOYER ADDRESSCITYSTATEZIP
❑ Self❑ Spouse❑ Daughter❑ Son❑ Other (specify) _______________
SPOUSE / DEPENDENT INFORMATION - Complete below if claim is for employee’s spouse or dependent.
NAMELASTFIRSTMIDATE OF BIRTH
IF DEPENDENT IS A STUDENT, GIVE NAME AND LOCATION OF HIS OR HER SCHOOLNUMBER 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 NAMELASTFIRSTMISUBSCRIBER SOCIAL SECURITY #
HOME ADDRESSDATE OF BIRTH (Mo / Day / Yr)GROUP #
CITYSTATEZIPIS THIS A NEW ADDRESSMARITAL STATUS
If yes, employer’s name
NAME OF REFERRING PHYSICIANDID YOU SELECT THIS PHYSICIAN FROM YOUR NETWORK DIRECTORY
IS THIS PHYSICIAN AFFILIATED WITH YOUR PMG / IPAIS THE INJURY OR ILLNESS WORK RELATED
DATE ACCIDENT OR ILLNESS OCCURREDDO 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 FORIF 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
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.
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