(01490-GBE.EN_PanB Claim. Guide 2013-10-25
PATIENT'S REQUEST FOR MEDICAL PAYMENT
IMPORTANT ~ SEE OTHER SIDE FOR INSTRUCTIONS
[PLEASE TYPE OR PRINT NFORWATION
MEDICAL INSURANCE BENEFITS SOCIAL SECURITY ACT.
NOTICE: Anyone who miopresens oe eserallformaton requested
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by hs frm may upon convection be subject fine and imprsenmet under
received a oqued b exiting ew androgens (20 CFR 422510),
ame of Beneisary fom Heath insurance Gard ‘SEND COMPLETED FORMTO:
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4. Ae you employed and covered under an employee heath plan? Ces OINe
bss your Spouse employed and are you covered under your spouses employee
heath plan? cles Ne
«: Ifyou have any medial coverage other than Medicare, suchas private insurance, employment related insurance,
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Name and Address of ther insurance, Site Agency (Medicaid 0 VA ofeo
I ROTHORGZE BAY HOLDER OF NEDIGAL OF OTHER FORMATION ABOUT NE TO RELENGE TO THE SOCIAL SECURITY AOMMTISTRATON
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JANo Gen teRs Fon weDicare & MEDICAD SERVICES OR ifs NTERMEDARIES OR GATRENS ANY INFORMATION NECOED FOR THIS OF A
Polcyhoder's Name:
RELATED MEDICARE CLAM. | PERMIT A COPY OF THIS AUTHORIZATION TO DE USED IN PLAGE OF THE ORIGINAL: AND REQUEST PAVVENT
[oe MEDICAL NGURANGE BENEFTS TO Me
Signature of Ptiant (I patent ¢ unable to.agn,ee8 Block on reverse)
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Note: l'you DO NOT want payment information on this claim eleased, put an (x) here
TMPORTANT
\CH ITEMIZED BILLS FROM YOUR DOCTOR(S) OR SUPPLIER(S) TOTHE BACK OF THIS FORM
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