Fillable Printable State Univerisity of New York Medical Reimbursement Form
Fillable Printable State Univerisity of New York Medical Reimbursement Form
State Univerisity of New York Medical Reimbursement Form
State University of New York
Medical Reimbursement Form –
Claims incurred inside the United States
Please use a separate claim form for each patient. Your cooperation in completing all items on the claim form, signing the back of the
form and attaching all required documentation will help us to process your claim quickly and accurately.
PLEASE TYPE OR PRINT • USE A SEPARATE FORM FOR EACH PATIENT
MEDICAL INFORMATION
PATIENT INFORMATION
PRIMARY POLICY HOLDER
INFORMATION (on ID Card)
NAME Last First Middle
CERTIFICATE NUMBER GROUP NAME
SUNY
COLLEGE/ UNIVERSITY NAME
BIRTH DATE SEX
M F
RELATION TO SUBSCRIBER
Self Spouse Son Daughter
NAME Last First Middle
DOES THE PATIENT HAVE OTHER HEALTH INSURANCE COVERAGE?
YES NO
ADDRESS
NAME OF OTHER HEALTH INSURANCE COMPANY
CITY STATE ZIP CODE
POLICY NUMBER of PRIMARY POLICY HOLDER
HOME PHONE NO.
( )
area code
COLLEGE ID NUMBER
INJURY
QUESTIONNAIRE
If the condition related to this referral is a result of an accident/injury, please complete the following section
Date of accident or
beginning
of condition:
Month Day Year
Describe exactly how the accident
took place
:
Please indica
te
if the injury was
related to any of the following
:
School related Injury Sports related injury Work related accident or illness Automobile/Motorcycle accident
intercollegiate sport
intramural sport
If the condition is a work related accident or a auto/motorcycle accident, please provide the following information:
Name of Employer:
(For work related accident)
Name of Insurance Carrier:
(For auto/motorcycle accident)
Policy #:
Address:
Phone Number: Contact:
MEDICAL INFORMATION
Use this section to report any COVERED health service which has not already been reported to this HTH Worldwide Plan. Attach itemized bill or
photocopy. Please be sure that duplicate bills are not submitted. Balance forward bills or canceled checks are not acceptable.
Date of Service
(Mo/Day/Yr)
Provider of Service
(Name of Doctor, Lab, Ambulance Company, etc.)
Se
rvice Rendered
(Office Visit, X-ray, Prescription, etc.)
Illness or Diagnosis
Total
(Please Indicate Currency)
GRAND TOTAL
SUNY Claim Form 0610
AUTHORIZATION
Certification and Release of Information: I certify that the information on this Claim Form is true and correct to the best of my knowledge. I
authorize the release of any medical information necessary to process this claim. This claim will be returned if this claim form is not signed.
Applicants applying for accident and health insurance in New York: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the
purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be
subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
X
Signature of Insured Member Date
Dear SUNY Member:
This form was developed for you to notify HTH Worldwide of any covered health services for which we have not already
been billed directly and to provide us with additional information that may be needed in order to process your claim. If a
hospital, physician, ambulance company or other provider send their bill directly to you, HTH Worldwide has no way of
knowing about your claim until the bill is received at HTH Worldwide.
Please read the following instructions about how to report health care services. We are happy to serve you.
THE FOLLOWING INFORMATION MUST ALSO BE INCLUDED ON BILLS FOR THE SERVICE TYPES LISTED BELOW
REGISTERED AND LICENSED VOCATIONAL NURSI
NG SERVICES
AMBULANCE
•
Hours and dates of service
•
Pick-up and delivery points
•
Location of service (residence or name of hospital)
•
Number of miles
•
Written documentation of physician’s referral (must include the state license number, plan of
treatment and estimated duration of treatments)
ANESTHESIA
•
Start Time
PROSTHETIC DEVICES, APPLIANCES OR DURABLE MEDICAL EQUIPMENT
•
End Time
•
Doctor’s orders or prescriptions
•
Surgical procedure
•
Purchase price
•
Surgeon Name and address
OUTPATIENT PRESCRIPTION DRU
GS
PHYSICAL THERAPY
•
Duplicate pharmacy generated receipt (not register tape)
•
Medical Records
•
Must include prescribing doctor’s name, name of medication, date filled and amount
•
Prescription from referring physician indicating
charged, Rx number; date filled; form, strength & quantity dispensed the number of visits prescribed
BILLS MUST BE ITEMIZED
Canceled check, cash register receipts and non-itemized “balance due” statements cannot be processed. If the bill is from a Hospital, Form UB-92 should
be submitted. If being billed from a doctor a HCFA-1500 is preferable. Each itemized bill must include:
• Name and address of provider (doctor, hospital, laboratory, ambulance service, etc.)
• Provider taxpayer I. D. number
• Name of patient
• Date(s) of service
• Amount charged for each service
• Total Charge
• Diagnosis Code or reason for treatment
• Procedure Code(s) description of services performed
PO Box 30259
Tampa, FL 33630
Telephone: 1.888.350.2002 Fax: 1.888.250.4121
Physicians/Providers:
For electronic filing Payor ID: 60054
Reminder:
This form is only to be used if treatment that was received in the United States.
I N S T R U C T I O N S F O R T H E U S E O F T H I S F O R M
