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W129 N7055 Northfield Drive Menomonee Falls, WI 53051 2625325200 Fax 2625325235Coordination of Benefits Form Welcome to Excellent! As the third party administrator for the Forester Health medical

How to fill out coordination of benefits form

How to fill out coordination of benefits form

1. Obtain a coordination of benefits form from your insurance company or employer.
2. Fill in your personal information such as name, address, phone number, and insurance policy number.
3. Provide information about the other insurance coverage you have, including the name of the insurance company, policy number, and group number.
4. Indicate which insurance plan should be considered primary and which should be secondary.
5. Sign and date the form before submitting it to the appropriate party.

Who needs coordination of benefits form?

1. Individuals who have more than one health insurance plan
2. Individuals who are covered by their own insurance as well as a spouse's insurance plan
3. Individuals who have both primary and secondary insurance coverage

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What is coordination of benefits form?

Coordination of benefits form is a form used in healthcare to determine which insurance plan will pay for a patient's medical expenses first when the patient is covered by more than one insurance plan.

Who is required to file coordination of benefits form?

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

How to fill out coordination of benefits form?

To fill out the coordination of benefits form, the individual must provide information about all insurance plans they are covered under, including policy numbers and effective dates.

What is the purpose of coordination of benefits form?

The purpose of coordination of benefits form is to prevent double payment for medical expenses and ensure that the correct insurance plan pays first.

What information must be reported on coordination of benefits form?

The coordination of benefits form must include information about all insurance plans the individual is covered under, including policy numbers, effective dates, and coverage details.