Fillable Printable Sample Child Coordination of Benefits Form

Sample Child Coordination of Benefits Form

Aetna - Dependent Child Coordination of Benefits Form

Section A:

Member Name: __________________________________________________

Aetna member ID Number or Social Security Number: ________________________

Do any of your children have other health care coverage?

_____ No…please check this line and sign this form at bottom.

_____ Yes…please complete Sections B and C below and sign this form at bottom.

Section B:

Please complete this section concerning your child/ren’s other coverage. If all children have the same

coverage, please list each child’s name; if children have different coverage, please prepare a separate

form for each child.

_____ Child/ren is covered by another Aetna plan and ID Number is ___________

_____ Child/ren is covered by another health insurance plan.

Name of the other health insurance plan is ____________________________________

Name of policyholder: __________________________________Birth date__________

Name of employer _______________________________________________________

Effective date of coverage: ________________ Date, if cancelled: ________________

Names of child/ren covered and birth date:

Child: _________________________________________________________________

If divorced, which parent has primary, physical custody? _____ Mother _____ Father

Thank you for completing this form, your responses will enable claims to be processed properly.

Your signature: ______________________ Daytime Phone Number: ______________

Please print this form, complete, and mail or fax to the following:

Aetna

PO Box 981106

El Paso, TX 79998-1106

Fax# 859-455-8650