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
Page 1/2
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State Univerisity of New York Medical Reimbursement Form PDF

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