Transcription of 1199SEIU Benefit Funds
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1199SEIU Benefit Funds
MEMBER reimbursement medical claim FORMP lease print clearly in blue or black A: MEMBER INFORMATION_____Member s full name Member ID #_____Address City State Zip code_____ Sex: M FPrimary telephone Date of birth_____Name of employer Date of hireCurrent marital status: Single Married Divorced Widowed Legally separatedDo you or your dependent child(ren) or spouse have other health insurance coverage? No Yes_____ Relationship to member: Self Spouse Dependent childIf yes, name of person covered_____Name of insurance plan Policy/Group number_____Insurance plan telephone Effective date of coveragePART B: PATIENT INFORMATION_____ Sex: M FPatient s full name Patient s date of birthPatient s relationship to subscriber: Self Spouse Dependent child Other: _____(Please specify)Is patient a dependent who is age 19 or older?
3af29 • 03/17 • member reimbursement medical claim My dependent child listed on previous page is 19 to 26 years of age and is my biological or adopted child. X
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