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.)
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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