Transcription of Health Insurance Program HEALTH INSURANCE …
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Health Insurance Program HEALTH INSURANCE …
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHERCHAMPUSHEALTH PLAN BLK LUNG(Medicare #) (Medicaid #) (Sponsor s SSN) (Memberchip ID#) (SSN or ID) (SSN) (ID)2. PATIENT S NAME (Last Name, First Name, Middle Initial)5. PATIENT S ADDRESS (No., Street)1a. INSURED S NUMBER (For Program In Item 1)3. PATIENT S BIRTH DATEMM DD YSEXMFCITYSTATEPICAZIP CODETELEPHONE (Include Area Code)( )4.
PLEASE MAIL CLAIMS TO: United HealthCare Insurance Company of New York P.O. Box 1600 Kingston, New York 12402-1600 1-877-7NYSHIP (1-877-769-7447) INSURANCE FRAUDS PREVENTION ACT
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