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. PATIENT AND INSURED INFORMATION. ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code). ( ) ( ). 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10.

The following statement is printed pursuant to Regulation 95 of the New York State Insurance Department: “Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact

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