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Coordination of Benefits Questionnaire

In order to properly coordinate your benefits, UnitedHealthcare needs to determine if you or your family members have other health care coverage. Accurate and complete information is required so that claims processing for your family will not be delayed. If you and/or other covered dependents have Medicare and other coverage, please submit a form for each type of coverage.

* REQUIRED
Do you or anyone in your family have other health care coverage?*
  No    If "No", please complete Section 1 and submit this form.
  Yes   If "Yes", please complete all of the applicable sections and submit this form.

Section 1. UnitedHealthcare Subscriber Information
       
Subscriber Name:*   Member ID#:*  
 
Do you have Medicare coverage?*
Yes (Skip to Section 5)
No (Continue with Section 2)
 
Section 2. Spouse Information (If not married, skip to Section 3)
     
Spouse's Name:   Spouse's Date of Birth:
   
Spouse's Current Employer/Company Name: Spouse's Social Security Number:
 
Section 3. Other Coverage Information
   
Other Insurance Name:* Other Insurance Member ID#:*
     
Other Insurance Address/Phone Number: Policy Effective Date:* Policy End Date:
     
Policyholder's Name:* Policyholder's Date of Birth:*
     
Policyholder's Employer/Company Name:    
   
   
Is the Policyholder:*
Type of Coverage:*
Full-Time Employee
Covered Through COBRA
Retired/Date of Retirement
Medical
Dental
Vision
Rx
   
Name(s) of covered dependent(s)
with dual coverage:*
Relationship to Policyholder:*
 
Are you divorced or legally separated from the Policyholder in Section 3, and do you have covered dependents under a UnitedHealthcare plan? *
Yes (Conitnue with Section 4)
No (Submit the form)
 
Section 4.
   
Name(s) of covered dependent(s):* Date of Divorce/Separation:
     
Name of Other Biological Parent:* Parent's Date of Birth:*
     
If divorced or legally separated:*
Divorce decree states other parent, , must provide health benefits.
Divorce decree states joint custody with shared responsibility for medical expenses.
Divorce decree does not state any special provisions pertaining to medical expenses.
Other, please explain:
     
With what parent does the child(ren) reside?*
 
Section 5. Medicare Coverage Information
If more than one family member has Medicare coverage, please submit a form for each covered member.
   
Member eligible for Medicare:* Medicare #:*
     
Effective Date of Part A: End Date of Part A:
     
Effective Date of Part B: End Date of Part B:
     
Effective Date of Part D: End Date of Part D:
   
Reason for Medicare Coverage:*
Age 65 or older
Disability - Date Disability Began:
ESRD - Date Dialysis Treatment Began:
 
      
 

UnitedHealthCare Services Company of the River Valley, Inc.
UnitedHealthcare Plan of the River Valley, Inc.
UnitedHealthcare Insurance Company of the River Valley