Transcription of The Empire Plan's Provider Directory
{{id}} {{{paragraph}}}
Example: biology
The Empire Plan's Provider Directory
New York State Government Employees Health Insurance Program CARRIER. UnitedHealthcare Box 1600. HEALTH INSURANCE CLAIM FORM Kingston, New York 12402-1600. APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 1-877-7 NYSHIP (1-877-769-7447). PICA PICA. 1. MEDICARE MEDICAID TRICARE CHAMPVA group FECA OTHER 1a. INSURED'S NUMBER (For Program In Item 1). HEALTH PLAN BLK LUNG. (Medicare #) (Medicaid #) (ID#/DoD#) (Member ID #) (ID #) (ID #) (ID #). 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial). MM DD YY. M F . 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street). Self Spouse Child Other . CITY STATE 8. RESERVED FOR NUCC USE CITY STATE.
11. insured’s policy group or feca number 30500 a. insured’s date of birth sex mm dd yy m f b. other claim id (designated by nucc) c. insurance plan name or program name empire plan a. other insured’s policy or group number b. reserved for nucc use c. reserved for nucc use d.
Loading..
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: