Transcription of www.empireplanproviders.com
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www.empireplanproviders.com
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).
INSURANCE FRAUDS PREVENTION ACT 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
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