Fillable Printable Member Reimbursement Form for Medical Claims and Prescription Drugs

Member Reimbursement Form for Medical Claims and Prescription Drugs

Member Reimbursement Form for Medical Claims

and Prescription Drugs

ONE FORM PER PATIENT PER PROVIDER

Please print clearly, complete all sections and sign. Retain copy for personal records.

1. Patient’s Name:

(Last) (First) (Middle)

2. Patient’s

Member I.D. #

3. Patient’s Date of Birth:

Patient’s Sex:  M  F

4. Subscriber’s Name:

(Last) (First) (Middle)

5. Subscriber

Member I.D. #

6. Patient’s Relationship to Subscriber:

 Self  Spouse  Child  Other

7. Patient’s Address:

8. Patient’s type of insurance:

 HMO  Options/Alliant  PPO  Medicare

9. Custodial Parent Information: For reimbursement requests from a Parent for a child (under the age of 18) when the

requesting Parent meets both of the following requirements:

1. Parent is not enrolled in the same Group Health plan as the child

2. Parent does not reside in the same household as the subscriber under the child’s Group Health plan

Legal Custodian’s Name: Legal Custodian’s Contact Phone #:

Custodian Requesting Reimbursement Name: Custodian Requesting Reimbursement Contact Phone #:

Address payment

is to be mailed to:

If your child is covered under two or more health plans, state law determines the order of beneﬁts for processing claims.

10. Practitioner Information:

Attending Practitioner’s Name:

Referring Practitioner’s Name:

11. Provider Information:

Provider’s Name:

Provider’s Tax I.D. #:

Provider’s Billing Address:

12. Condition was related to:

A. Patient’s Employment? L&I

 Yes  No

B. Auto Accident?

 Yes  No

C. Date of Incident:

13. The following information must be obtained from your provider, or must be included on your itemized

statement from your provider. Do not send originals as they will not be returned to you.

Dates of

Service

Place of Service

(Ofﬁce, ER, Urgent, Hospital, Clinic,

Pharmacy, Ambulance, Home)

Diagnosis Code

(DX)

Procedure Codes Units/ Days

Amount

Paid

14. Pharmacy Charges: Please attach legible copies of receipts / dispensing list that include all of the following information:

1) Fill Date 2) Drug Name 3) Drug Strength 4) Quantity 5) Days Supply 6) Prescription Number 7) Your Cost / Amount

Rev. Date 2013228

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15. Foreign Claims:

For services out of country, please provide name of country:

Where services were rendered:  Ofﬁce/ Clinic  ER  Urgent Care  Hospital  Pharmacy

Please explain injury or illness:

Itemized bills, receipts, and statements must be translated prior to submittal. Translation will be at the members expense.

16. I have attached one of the

following proof of payments:

 The front and back of the cleared

check written to the provider, or

bank encoded copy of the front

check written to the provider.

 A copy of a credit card statement

that includes the charges and the

provider’s name.

 A copy of the receipt, with the

provider’s name and address

preprinted on the receipt.

Note: Itemized statements/ invoices

do not count as proof of payment.

17. Information about payment(s)

made:

Was there a discount for the services?

 Yes  No

If Yes, is the amount paid after the discount?

 Yes  No

Is there a balance due?

 Yes  No

Note: if there is a balance due to the provider

you may not be entitled to a refund.

18. Other Insurance information:

Is the patient covered by another health

plan?  Yes  No

Subscriber name for other insurance:

Name of other insurance company:

Did other insurance make a payment?

 Yes  No

If yes, include Explanation of Beneﬁts

from other insurance plan(s).

19. Signature is required:

I attest that the above information is true and accurate, and the services were received and paid for in the amount requested as

indicated above. I acknowledge that if any information on this form is misleading or fraudulent, my coverage may be cancelled and

I may be subject to criminal and / or civil penalties for false health care claims.

Signature: Date:

For any questions please contact Customer Service toll-free at 1-888-901-4636, (TTY Relay: 711 or 1-800-833-6388). Or visit ghc.

org, click on “Customer Service” and send an email.

Reimbursement requests will be processed within 45 days of receipt.

Itemized receipts, invoices, and proof of payment must be submitted, otherwise form may be sent back for lack of information.

Submit all documents to:

Claims Processing

Group Health Cooperative

PO Box 34585

Seattle, WA 98124-1585

Member Reimbursement Form for Medical Claims and Prescription Drugs Instructions

Please complete all items on the claim form. If the information requested does not apply to the patient, indicate N/A (Not Applicable). Special

care should be taken when completing the following sections:

10. Practitioner Information – Please ﬁll out attending practitioner’s name with the physician that was seen for services. Please ﬁll referring

practitioner’s name with the physician that referred you if applicable.

11.

Provider Information – Please ﬁll out provider name with the name of the facility that was visited. Please ﬁll out Provider Tax ID with the

facility’s Tax ID (this number will need to be obtained from the provider). Please ﬁll out provider billing address with the facility’s address.

12. Condition was related to – Please indicate if the injury or reason of visit was related to your employment (L&I), or an auto accident, and

if yes to either of them please indicate the date of accident.

13. Itemization – This information must be obtained from your provider, or must be included on your itemized statement from your

provider. If this information is included on your itemized statement you can state please review attached itemized statement.

14. Pharmacy Charges – Please attach legible copies of receipts / dispensing lists that include ﬁll date, drug name, drug strength, quantity,

days supply, prescription number, and your cost / amount paid.

15. Foreign Claims – Please complete this section if your services were completed outside of the country, otherwise indicate N/A.

16. Proof of payment – Please indicate what type of proof of payment you have attached with this form.

17. Payment information – Please answer each question by checking the box that applies to the payment(s) you made to the provider.

18. Other insurance – Please indicate whether you have coverage from another insurance, if applicable the name of the subscriber for the

other insurance and the name of the other insurance, and indicate by checking the box if they made a payment.

19. Signature – This form must be signed and dated by either the subscriber or the patient.

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