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SHEET METAL WORKERS 4530 Roosevelt Road Hillside, IL 60162-2053 Phone 708-449-7373 Fax 708-449-7458 LOCAL UNION NO. 73 WELFARE FUND Coordination of Benefits Form 2014 Your insurance with Sheet Metal

How to fill out 2004 coordination of benefits

How to fill out 2004 coordination of benefits:

1. Obtain the 2004 coordination of benefits form from the relevant healthcare provider or insurance company. It may also be available online on their website.
2. Begin by providing your personal information, such as your full name, address, date of birth, and contact details. Make sure to use accurate and up-to-date information.
3. Identify the primary insurance information by filling in the details of your primary insurance plan. This includes the name of the insurance company, policy or group number, and the primary subscriber's information if applicable.
4. Move on to the secondary insurance information section. Provide the details for your secondary insurance plan, including the name of the insurance company, policy or group number, and any necessary subscriber information.
5. Indicate the reason for coordination of benefits. This could include situations such as being covered by both an employer-sponsored plan and a spouse's plan, or having coverage under both Medicare and a private insurance plan.
6. If you have any other insurance coverage, such as through a self-insured employer plan or a government program, complete the relevant section accordingly.
7. Review the completed form for accuracy and ensure all required fields are completed. Double-check that you have provided the correct policy numbers and relevant subscriber information.
8. Sign and date the form at the designated spot to certify the accuracy of the information you have provided.

Who needs 2004 coordination of benefits?

1. Individuals who have multiple health insurance plans or coverage options may need to fill out a 2004 coordination of benefits form.
2. This form is typically required in situations where an individual has primary insurance coverage under one plan and secondary insurance coverage under another plan.
3. Employed individuals who have both their own employer-sponsored health insurance and coverage as a dependent under a spouse's plan may also need to complete this form to coordinate benefits accurately.
4. Those who are covered under Medicare but also have additional private insurance coverage would also be in need of coordinating benefits using the 2004 coordination of benefits form.
5. In summary, anyone with multiple sources of health coverage would need to complete the 2004 coordination of benefits form to ensure proper coordination and avoid payment disputes.

For pdfFiller’s FAQs

What is coordination of benefits?

Coordination of benefits is a process used by health insurance companies to determine the order of payment when a patient is covered by more than one insurance plan.

Who is required to file coordination of benefits?

The primary insurance company is typically required to file coordination of benefits.

How to fill out coordination of benefits?

Coordination of benefits can be filled out by providing information about any other insurance coverage the patient may have.

What is the purpose of coordination of benefits?

The purpose of coordination of benefits is to prevent overpayment and ensure that each insurance company pays its fair share.

What information must be reported on coordination of benefits?

Information such as the names of the insurance companies, policy numbers, and other coverage details must be reported on coordination of benefits.

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