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Associated Administrators, LLC FCW Local 1500 Welfare Fund P. O. Box 1095 Sparks, Maryland 211521095 Phone: (855) 2661500 www.associatedadmin.com Coordination of Benefits Questionnaire Dear Plan Participant,

How to fill out coordination of benefits questionnaire

How to fill out a coordination of benefits questionnaire:

1. Begin by carefully reading the instructions provided with the coordination of benefits questionnaire. Make sure you understand the purpose and requirements of the form.
2. Gather all the necessary information before starting to fill out the questionnaire. This may include your personal details, such as name, address, date of birth, and contact information. You may also need information about your current health insurance coverage, including policy number, insurance company name, and any group or employer information.
3. Review your health insurance coverage documents to understand the benefits and limitations of your plan. This will help you accurately complete the questionnaire and provide correct information.
4. Start filling out the coordination of benefits questionnaire by entering your personal details in the designated fields. Make sure to double-check the accuracy of your information to avoid any errors or delays in processing.
5. Provide information about your current health insurance coverage. This may include details about your primary insurance plan, such as the insurance company's name, policy number, and group or employer information. If you have any secondary insurance, provide the required information for that plan as well.
6. Answer all the questions on the questionnaire truthfully and to the best of your knowledge. If you have any doubts or are unsure about how to answer a particular question, seek assistance from your insurance provider or a professional who can guide you through the process.
7. Once you have completed filling out the coordination of benefits questionnaire, carefully review all the provided information. Look for any mistakes or omissions and make corrections if necessary.
8. Sign and date the completed questionnaire as required. Some questionnaires may require additional attestations or signatures, so make sure to read the instructions carefully.
9. Make a copy of the filled-out coordination of benefits questionnaire for your records before submitting it to the relevant party, such as your insurance company or healthcare provider.

Who needs a coordination of benefits questionnaire?

1. Individuals who have multiple health insurance plans may need to fill out a coordination of benefits questionnaire. This form helps determine which insurance plan is the primary payer and which is the secondary payer for a specific claim or medical service.
2. People who have private health insurance coverage through their employer may need to complete a coordination of benefits questionnaire when they have additional coverage through a spouse or parent's insurance plan.
3. Individuals who are eligible for both Medicare and another insurance plan, such as Medicaid or a private insurance policy, will often need to fill out a coordination of benefits questionnaire to determine the primary and secondary payers for their medical expenses.

Remember to consult with your insurance provider or healthcare professional for specific guidance on filling out a coordination of benefits questionnaire in your unique situation.

For pdfFiller’s FAQs

What is coordination of benefits questionnaire?

Coordination of benefits questionnaire is a form used to determine which health insurance plan pays first when an individual is covered by multiple insurance plans.

Who is required to file coordination of benefits questionnaire?

The policyholder or the individual covered by multiple insurance plans is required to file coordination of benefits questionnaire.

How to fill out coordination of benefits questionnaire?

To fill out coordination of benefits questionnaire, you need to provide information about all the insurance plans you are covered by and any other pertinent information requested on the form.

What is the purpose of coordination of benefits questionnaire?

The purpose of coordination of benefits questionnaire is to prevent overpayment by ensuring that claims are properly processed by the primary insurance plan.

What information must be reported on coordination of benefits questionnaire?

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

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