Subscriber In Insurance Form

In a generic sense a health insurance subscriber may also be called a policyholder certificate holder insured or covered participant.

Subscriber in insurance form. Patient control number and the medical record number for your facility. An insurance subscriber is the person who subscribes to the insurance or in other terms an insurance subscriber is the policyholder who pays for a specific insurance plan. Billing provider s pay to name address city state zip and id if it s different from field 1. 2d subscriber identification number including prefix 2e address number and street.

Any dependents should have the same insurance information as that of the subscriber. Type of bill tob this is a four digit code beginning with zero. The subscriber is the primary adult who applied for insurance. Subscriber s address street city state zip code a.

Billing provider name street address city state zip telephone fax and country code. Dwc005 notice of non coverage annual filing period february 1 april 30. Subscriber is normally used to describe someone covered under an hmo plan although the term has broad use and application. If you are a non subscriber you must file dwc form 005 employer notice of no coverage or termination of coverage each year by april 30 or when you end your coverage check out our video tutorial below for help filling out this form.

Reciprocity self spouse child other 9. The subscriber must provide the information requested below to obtain approval for access to the electronic insurance forms submission program and to obtain a user identification number and password for the program. A nonproÿt independent licensee of the bluecross blueshield association subscriber patient information 2i patient s last name. 10 was condition related to 11.

Terms can be confusing but the use of subscriber is often a legal definition used when a policy is not issued to the individual. Subscriber request form subscriber s information. Subscriber claim form 2a subscriber s last name 2b first name. That person becomes the subscriber.

What is a subscriber on. In households who get insurance through other means. Other health insurance enter name and address of other insurance policy holder of other insurance and policy holder s employer.