Get the free Coordination of Benefits Form - EBS-RMSCO, Inc

Coordination of Benefits Form Please complete the information below and return this form to EBS Benefit Solutions, Inc. If you have questions regarding this form, please contact our Customer Service

How to fill out coordination of benefits form

How to fill out a coordination of benefits form:

1. Start by gathering all relevant information, including your primary insurance information, such as policy number and group number, and any secondary insurance information you may have.
2. Ensure that you have a copy of the medical bills or claims that you wish to coordinate benefits for. This will help you accurately fill out the form.
3. Open the coordination of benefits form provided by your insurance company or employer. It is typically available on their website or can be obtained by contacting customer service.
4. Begin by entering your personal information, such as your name, address, date of birth, and social security number.
5. Provide details about your primary insurance coverage by entering the policy number, group number, and name of the insurance company.
6. Fill in the information about your secondary insurance coverage, including the policy number, group number, and insurance company name.
7. Indicate the relationship of the primary and secondary policyholders, such as spouse, parent, or self if you have both primary and secondary coverage.
8. Specify the type of primary and secondary policies you have, such as health, dental, or vision insurance.
9. If required, provide information about your workplace or employer, including the name and address.
10. Review the form to ensure that all the information provided is accurate and complete. Make any necessary corrections or additions.
11. Sign and date the form to attest that the information provided is true and accurate.
12. Make a copy of the completed coordination of benefits form for your records before submitting it to your primary insurance company.

Who needs coordination of benefits form?

1. Individuals who have multiple insurance policies, such as primary and secondary coverage, may need to fill out a coordination of benefits form.
2. Employees who have workplace-provided insurance and additional coverage from a spouse or parent may require a coordination of benefits form.
3. Those who want to ensure that their medical expenses are adequately covered by multiple insurance policies can benefit from filling out a coordination of benefits form.
4. Individuals who are entitled to benefits from both private insurance and government health programs, such as Medicare or Medicaid, may need to complete a coordination of benefits form.
5. Any policyholder who wants to prevent overpayment or duplicate coverage issues should consider filling out a coordination of benefits form to clarify how their insurance policies interact with each other.

For pdfFiller’s FAQs

What is coordination of benefits form?

Coordination of benefits form is a document used in the healthcare industry to determine the primary and secondary health insurance coverage for an individual who has multiple insurance policies.

Who is required to file coordination of benefits form?

The policyholder or insured individual is typically required to file the coordination of benefits form.

How to fill out coordination of benefits form?

To fill out the coordination of benefits form, you will need to provide information about all insurance policies you have, including policy numbers, coverage details, and any other relevant information.

What is the purpose of coordination of benefits form?

The purpose of the coordination of benefits form is to avoid duplicate payments and determine the order in which multiple insurance policies should be billed.

What information must be reported on coordination of benefits form?

Information such as policy numbers, coverage details, and any other relevant insurance information must be reported on the coordination of benefits form.

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