Standard Medical Insurance Form Number

If yes list policy or contract holder policy or contract number s and name address of insurance company or administrator.

Standard medical insurance form number. Insured s name last name first name middle initial 7. Insurance products and services are offered by reliance standard life insurance company in all states except new york the district of columbia puerto rico the u s. Use this form to file an accident insurance claim. If you are covered by other health insurance either in your name or under a family member s policy check yes and complete item 10.

Is there another health benefit plan. Virgin islands and guam. Insured s date of birth b. Yes complete items 9 9a and 9d.

It is intended to assist providers by streamlining the data submission process for selected services that require prior authorization. This number is on your medicare card. Insured s policy group or feca number sex. Department of insurance the texas health and human services commission or the patient s or subscriber s employer.

The table for health care allowances is based on medical expenditure panel survey data and uses an average amount per person for taxpayers and their dependents under 65 and those individuals that are 65 and older. In new york insurance products and services are offered by first reliance standard life insurance company home office new york ny. Standard health insurance claim form. Uses for standard form sf 2809.

The form is designed to serve as a standardized prior authorization form accepted by multiple health plans. Read back of form before completing signing this form. The out of pocket health care standard amount is allowed in addition to the amount taxpayers pay for health insurance. Insured s address no street 11.

Insurance plan name or program name yes. Print using either the print button at the end of the form or the print icon located on the adobe toolbar. Authorization to release health related information. Member s id number 23.

Balanced care vision plan iii claim. Number for program in item 1 4. Beginning september 1 2015 health benefit plan issuers must accept the texas standard prior authorization request form for health care services if the plan requires prior authorization of a health care service. Cross blue shield etc no fault auto insurance medicare or any federal state or local government plan.

Provide the information requested on any other health. Insured s policy group or feca number. Sign and date the form then make a copy for your records.