Complete the enrollment form on the reverse side to join Onyx 360 today.
|
|
- Daniella Grant
- 8 years ago
- Views:
Transcription
1 Complete the enrollment form on the reverse side to join Onyx 360 today. Oncology Nurse Advocates are available Monday through Friday, from 9 am to 8 pm Eastern Standard Time at ONYX-360 ( ) to help guide you and your patients through the specifics of the program(s) and answer any questions you or your patients might have. Onyx Pharmaceuticals 360 PO Box Charlotte, NC Onyx, Onyx Pharmaceuticals, Onyx Pharmaceuticals logo, and Onyx Pharmaceuticals 360 are all trademarks of Onyx Pharmaceuticals, nc Onyx Pharmaceuticals, nc., South San Francisco, CA TROPC-ONYX November 2014 Printed in USA
2 Onyx 360 is a comprehensive, personalized program designed to provide information and assistance to patients in their health journey, including! Reimbursement Assistance Co-pay/co-insurance assistance through independent third-party foundations nformation and assistance with insurance verifications Prior authorization and appeals process information! Free product assistance for uninsured patients or those rendered uninsured through payer denial who meet certain income eligibility criteria! Referral to third-party organizations for those patients who qualify and need assistance with or help paying for gas, lodging, tolls, and parking in connection with receiving therapy! Referral to support services for patients, families, and caregivers that provide product information, support group information, nutritional information, side effect management, along with practical matters related to the patient s condition Please complete the enrollment form for service(s) requested. Failure to include all information will delay the process. Please see required information below for each requested service. All services are subject to eligibility requirements.! nsurance Verification Complete sections Fax a copy of the front and back of the patient's insurance card with the enrollment form! Free Product Assistance Complete sections Patient s financial documentation will be required (i.e., most recent 1040 federal tax return, W2, or Social Security statement) Physician and patient signatures are required! ndependent Foundation Co-pay Assistance Complete sections ! Referral to Transportation and Lodging Cost Assistance Complete sections 1 2 5! Referral to Patient Support Services Complete sections Upon submission of the enrollment form to Onyx 360, an Oncology Nurse Advocate will confirm receipt with your office and initiate the services you requested on behalf of your patient(s) after all required documentation and information has been provided.
3 ZP Physician Declaration ZP certify that the patient and physician information contained in this enrollment form is complete and accurate to the best of my knowledge and that have prescribed based on my professional judgment of medical necessity. f requested, authorize Onyx 360 to perform a preliminary assessment of insurance verification for the above-named patient, and further authorize and request that am provided with all information necessary for me to complete a Letter of Medical Necessity for my patient, as may be required as a result of such insurance verification assessment. f my patient is approved for free product assistance by Onyx 360, certify that neither nor anyone on my behalf shall submit a claim to any third-party payer for payment of product provided under Onyx 360. will ensure that any patient receiving free product assistance by Onyx 360 who is enrolled in a federal healthcare program such as Medicare or Medicaid will receive such free product during the entire time that patient is enrolled in this program, regardless of whether a federal healthcare program payer subsequently determines that it will cover the product during that time. will check with my local Medicare contractor, my state Medicaid program, or the appropriate payer to confirm whether and how should reflect the no-charge dose on claims submitted for the associated procedure. warrant that any product provided to me under Onyx 360 will only be used for the approved patient and will not be sold, traded, or returned for credit required. Prior to transmittal of any personal health information (PH), certify that have obtained the legally required patient verbal or written authorization for services selected above. D
4 (ii) (iii), will (i) My signature at right certifies that agree to join the Onyx 360 patient support program and that have read, understand, and agree to the Privacy Notice and Patient Authorization to release my personal health information as described in full detail on the following pages.
5 Uses and Disclosure of Personal nformation authorize Onyx Pharmaceuticals, nc., an Amgen subsidiary, and its contractors ( Onyx ) to use and/or disclose my personal information, including my personal health information, for the following purposes: To enroll me in and/or continue my participation in the ONYX 360 program or any other thirdparty patient support services and related activities; To contact, upon my permission, my health care team (including my doctor and his team) and share with them some of my important health information; To provide me with informational and marketing materials relating to Onyx products and services, and/or my condition or treatment; and/or To improve, develop, evaluate and continue products, services, materials and programs related to my condition or treatment. also authorize any health care providers, health care plans, pharmacies, pharmaceutical companies, laboratories and/or their contractors ( Health Care Providers ) to disclose any of my personal health information to Onyx and its contractors as requested by Onyx and as necessary for the purposes stated in this Authorization. understand that my personal health information includes any information, in electronic or physical form, in the possession of or derived from a health care provider, health care plan, pharmacy, pharmaceutical company, and/or contractor regarding: (1) my medical history, including my entire medical file and complete patient history; (2) my health care plan benefits; (3) limits or restrictions on payments covered by my health care plan policy; and/or (4) my health or my adherence to my treatment. Expiration, Right to Obtain a Copy and Right to Cancel understand that Onyx may use my personal information, including my personal health information, for five years once sign this Authorization or for a shorter time period if required by state law. am entitled to receive a copy of this Authorization. also understand that can cancel this Authorization at any time by calling ONYX-360 ( ). Once Onyx receives and processes my cancellation, it will not use my personal information going forward; however, understand that cancelling my Authorization will not affect any use of my personal information that occurred before my request was processed. further understand that if a Health Care Provider is disclosing my personal health information to Onyx on an on-going basis as authorized herein, my cancellation with Onyx will only be effective with respect to any
6 such Health Care Providers once they actually receive notice of my cancellation from Onyx. No Effect on Treatment understand that the Onyx 360 program providers will receive compensation from Onyx for providing Onyx 360 services. understand that do not have to agree to the uses and disclosures of my personal information contained in this Notice and Authorization. understand that Onyx, as well as Health Care Providers, cannot require me, as a condition of receiving medications, prescription drugs, treatment or other care, to sign this Authorization. However, also understand that Onyx cannot provide me with any of the services contained in the Notice and Authorization without my authorization, including but not limited to, my enrollment or continued participation in patient support services. Under these circumstances, may be responsible for the full costs of my treatment. nformation Received from Health Care Providers understand that where a Health Care Provider discloses my personal health information to Onyx for the purposes contained in this Notice and Authorization, the personal health information disclosed may not be covered by any federal law relating to the use of my personal health information or how it is disclosed. There is no guarantee that my personal health information received by Onyx from a Health Care Provider might not be released to a third party. further understand that if a Health Care Provider is disclosing my personal health information on an on-going basis to Onyx, this Authorization only permits Health Care Providers to do so for 1 year once sign it or a shorter time period if required by state law. understand that may choose to be contacted by Onyx by mail, , phone, and/or SMS/text, as indicated above, for any of the purposes stated in this Authorization and that such communications may include the use of prerecorded voice messages and autodial systems.
These are just some of the eligibility requirements meeting these criteria does not guarantee acceptance.
BARACLUDE PATIENT ASSISTANCE PROGRAM The Baraclude Patient Assistance Program is designed to provide free medication to qualifying patients who do not have prescription drug coverage and are having a hard
More informationCo-Pay Assistance Program for CUBICIN (daptomycin for injection) for Intravenous Use Enrollment Form
1. PATIENT INFORMATION Name Gender: o Male o Female Date of Birth: / / Address City State ZIP Email Home Phone Cell Phone Work Phone Alternate Contact Person (Optional) Alternate Phone Number (Optional)
More informationSUPPORT PATH PROGRAM INTAKE FORM PHONE: 1-855-769-7284 FAX: 1-855-298-8700
SUPPORT PATH PROGRAM INTAKE FORM PHONE: 1-855-769-7284 FAX: 1-855-298-8700 1 REQUESTED SERVICE(S) (REQUIRED) CHECK ALL BOXES THAT APPLY Benefits Investigation Prior Authorization and Appeals Support Patient
More informationBristol-Myers Squibb Access Support Program. What Medications does the BMS Access Support Program help with? Program Registration Steps
Oncology Reimbursement Support Phone: 1-800-861-0048 Fax: 1-888-776-2370 Bristol-Myers Squibb Access Support Program The Bristol-Myers Squibb Access Support Program is designed to help patients with reimbursement
More informationEnroll in Interconnect
Enroll in Interconnect Enrollment Form Checklist In this packet, you will find all of the necessary forms to enroll your patients in Interconnect and give them access to a full suite of support services
More informationWelcome to. Prompt Fulfillment and Delivery 1-844-CUBIST-CARES (1-844-282-4782)
Welcome to When you prescribe SIVEXTRO (tedizolid phosphate) to your patients, our goal is to ensure they have access. That is why AccessSIVEXTRO is committed to helping eligible patients so they can receive
More informationNOVARTIS SERVICE REQUEST FORM FOR PATIENT SUPPORT
NOVARTIS SERVICE REQUEST FORM FOR PATIENT SUPPORT Please complete the Fax Cover Sheet and Service Request Form, and fax all pages to the number specified below. Dear Health Care Professional: The Novartis
More informationPatient Financial Policies
Patient Financial Policies Diabetes & Internal Medicine Associates, PLLC 2302 E. Terry St., Pocatello, ID 82301 208-235-5910 Fax 208-235-5920 Thank you for choosing Diabetes & Internal Medicine Associates,
More informationWelcome Information. Registration: All patients must complete a patient information form before seeing their provider.
Welcome Information Thank you for choosing our practice to take care of your health care needs! We know that you have a choice in selecting your medical care and we strive to provide you with the best
More informationMedication Therapy Management Program. A service for better understanding and managing the drugs you take at no additional cost to you.
Medication Therapy Management Program A service for better understanding and managing the drugs you take at no additional cost to you. Better information for better outcomes at no additional cost to you
More informationPowered by iassist. User Guide and FAQs
User Guide and Helpful information about, how to use the platform, and answers to some frequently asked questions () Table of Contents Click an option below to get started Setting up your account eprescribing
More informationApplication Form Instructions
Who qualifies for this program? To qualify, you must meet ALL of the requirements listed below: Ø My doctor has prescribed a Lilly drug for me. Ø I am a permanent, legal resident of the United States or
More informationInsurance Intake Form, Authorization and Assignment of Benefits
Recipient Information Insurance Intake Form, Authorization and Assignment of Benefits Return completed and signed form with copies of insurance card(s), front and back, to: Fax: (303) 200-5441 E-mail:
More informationNOVARTIS SERVICE REQUEST FORM FOR PATIENT SUPPORT
NOVARTIS SERVICE REQUEST FORM FOR PATIENT SUPPORT Please complete the Fax Cover Sheet and Service Request Form, and fax all pages to the number specified below. Dear Health Care Professional: The Novartis
More informationFrequently Asked Billing Questions
Frequently Asked Billing Questions How will I be billed? Mayo Clinic Health System will send you a billing statement with your charges. Provider charges for clinic and hospital services will be billed
More informationMedicare Supplement Coverage Options
Medicare Supplement Coverage Options Thank you for your interest in our Medicare Supplemental coverage options, also known as Traditional Blue (Medigap) policies. The Medicare Supplement Plans, when combined
More informationOak Ridge National Laboratory. New Coverage New Choices
Oak Ridge National Laboratory New Coverage New Choices What we ll cover today What is changing and why? How this affects you Introducing Extend Health Medicare marketplace Going forward Questions & answers
More informationMemorial Hermann Advantage (HMO)
Memorial Hermann Advantage (HMO) 2016 Enrollment Form Follow these easy steps to enroll in a Memorial Hermann Advantage Health Maintenance Organization (HMO). 1. Each applicant must fill out a separate
More informationNovo Nordisk Product Assistance/Trial Program Application
The Hemophilia and Rare leeding Disorder Product ssistance Program (PP) provides medication to qualifying applicants at no charge. If the applicant qualifies under the PP guidelines, the prescribed dose
More informationMedical and Rx Claims Procedures
This section of the Stryker Benefits Summary describes the procedures for filing a claim for medical and prescription drug benefits and how to appeal denied claims. Medical and Rx Benefits In-Network Providers
More informationArizona Department of Health Services Division of Behavioral Health Services PROVIDER MANUAL NARBHA Edition
NARBHA Edition Section 3.5 Third Party Liability and Coordination of Benefits 3.5.1 Introduction 3.5.2 References 3.5.3 Scope 3.5.4 Did you know? 3.5.5 Objectives 3.5.6 Definitions 3.5.7 Procedures 3.5.7-A:
More informationELECTION FORM. Important information about this election form PLEASE READ ALL PAGES BEFORE SIGNING THIS FORM. About the application process
Senior Advantage ELECTION FORM Important information about this election form PLEASE READ ALL PAGES BEFORE SIGNING THIS FORM. Please type or print legibly, using a black or blue ballpoint pen, and press
More informationConroe Physician Associates. Patient Consent Form. I fully understand that this is given in advance of any specific diagnosis or treatment.
Conroe Physician Associates Patient Consent Form Please Read and Sign I, undersigned, hereby consent to the following: Administration and performance of all treatments Administration of any needed anesthetics
More informationZimmer Payer Coverage Approval Process Guide
Zimmer Payer Coverage Approval Process Guide Market Access You ve Got Questions. We ve Got Answers. INSURANCE VERIFICATION PROCESS ELIGIBILITY AND BENEFITS VERIFICATION Understanding and verifying a patient
More informationAbout the Program 1. What is the current Osphena (ospemifene) Savings Offer for 30 day prescription?
2015 Osphena Savings Program Frequently Asked Questions Click here for Full Prescribing Information, including Boxed WARNING regarding Endometrial Cancer and Cardiovascular Disorders. Have a question about
More informationMember s Name First M.I. Last Dependent s Name (if enrolling in Medicare) First M.I. Last
Oklahoma State and Education Employees Group Insurance Board A Division of the Office of State Finance APPLICATION FOR MEDICARE SUPPLEMENT WITH PART D Member ID # *MCENRL* Phone ( ) Member s Name First
More informationPublication CM-6 March 2013. Black Lung Medical Benefits: Questions and Answers about the Federal Black Lung Program
Publication CM-6 March 2013 Black Lung Medical Benefits: Questions and Answers about the Federal Black Lung Program U.S. Department of Labor Office of Workers Compensation Programs Black Lung Medical Benefits:
More informationPatient Assistance Application for HUMIRA (adalimumab)
The AbbVie Patient Assistance Foundation provides AbbVie medicines at no cost to patients experiencing financial difficulties. Eligible patients typically have no healthcare coverage for the requested
More informationApplication Form Instructions
The Lilly Cares Foundation, Inc., a private operating foundation, offers the Lilly Cares patient assistance program to help qualifying people get selected Lilly medications. What products are included?
More informationFrequently Asked Questions About Your Hospital Bills
Frequently Asked Questions About Your Hospital Bills The Registration Process Why do I have to verify my address each time? Though address and telephone numbers remain constant for approximately 70% of
More informationAgreement to Send Electronic Florida Medicare
Agreement to Send Electronic Florida Medicare Instructions for completing this form: 1. Complete one agreement for the group. 2. Please complete the following: EDI Enrollment Form, Section C Complete the
More information2016 Enrollment Form
2016 Enrollment Form White Copy Enrollment Yellow Copy Agent Pink Copy Member Simply Healthcare Scope Lead ID: Black & White Logos Proposed Effective Date of Coverage: Horizontal 2016 Enrollment Request
More informationPATIENT APPLICATION FORM INSTRUCTIONS
INSTRUCTIONS The Safety Net Foundation is a nonprofit patient assistance program that helps qualifying uninsured patients access Amgen medicines at no cost. To apply online, access program information
More informationHIPAA Security Manual Administrative Security/Omnibus Rule
Notice of Privacy Policies Form ***This notice describes how medical information about you may be used and disclosed and how you can get access to this information. PLEASE READ IT CAREFULLY!*** The tells
More informationEnrollment Application. Senior Blue Traditional Blue Medicare PPO
MEDICARE ADVANTAGE Enrollment Application Senior Blue Traditional Blue Medicare PPO 30 Century Hill Drive, Latham, NY 12110 1-800-700-8482 Toll Free TTY/TDD (Hearing Impaired) 1-877-513-1470 Monday through
More informationVantage Health Plan, Inc. 130 DeSiard Street, Suite 300. Monroe, LA 71201. Vantage Health Plan, Inc.
Vantage Medicare Advantage Medicare Advantage Enrollment Election Form Vantage Health Plan, Inc. Please contact Vantage Health Plan, Inc. if you 130 need Desiard information Street, in Suite another 300
More informationAtlanta Diabetes Associates Patient Registration Form. Patient Name: First Middle Last. Address: City: State: Zip Code:
Atlanta Diabetes Associates Patient Registration Form : Chart #: Which Doctor are you seeing today: _ Patient Name: First Middle Last Address: City: State: Zip Code: _ Home Phone: Work Phone: of Birth:
More informationTo Enroll in Cigna HealthSpring Preferred Plus, Please Provide the Following Information:
Cigna HealthSpring Preferred Plus (HMO) Medicare Advantage Plan 2015 Enrollment Request Form Please contact Cigna HealthSpring Preferred Plus if you need information in another language or format (Braille).
More information9180 Katy Fwy Houston, TX 77055 713-984-1400 aokmedicalcenter.com
Effective Date: September 23, 2013 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have
More informationEmeriti Retirement Health Solutions Qualified Medical Expense Claim Form Effective January 1, 2012
1 Emeriti Retirement Health Solutions Qualified Medical Expense Claim Form Effective January 1, 2012 Please use this Claim Form to submit claims for the reimbursement of Qualified Medical Expenses, otherwise
More informationAnnual Notice of Changes for 2015
Express Scripts Medicare (PDP) for Consolidated Associations of Railroad Employees (CARE) Annual Notice of Changes for 2015 You are currently enrolled as a member of Express Scripts Medicare (PDP). The
More informationPatient Assistance Resource Center Health Insurance Appeal Guide 03/14
Health Insurance Appeal Guide 03/14 Filing a Health Insurance Appeal Use this reference guide to understand the health insurance appeal process, and the steps to take to have a health plan reconsider its
More informationENROLLMENT APPLICATION. Vista Healthplan Of. Vista South Florida
2009 ENROLLMENT APPLICATION Vista Healthplan Of South Florida, Inc. Vista South Florida Individual Enrollment Request Form To Enroll in Vista Healthplan of South Florida, Inc., Please Provide the Following
More informationNOTICE OF PRIVACY PRACTICES
NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE OF PRIVACY PRACTICES
More informationElection Form California Region Group Plan
Senior Advantage (HMO) Election Form California Region Group Plan Important information about this election form PLEASE READ ALL PAGES BEFORE SIGNING THIS ELECTION FORM Please type or print legibly, using
More informationPATIENT INFORMATION. Patient: S.S.# Address: D.O.B. Home Phone: Bus Phone: Male Female. Emergency contact: Relation to Patient: PH#
Massage 258 West 91 st Street, Suite 1-B Physical THERAPY EXPERTS, PLLC WELCOME 212-875-8345 T PLEASE FILL IN FORM COMPLETELY TO AVOID INSURANCE PAYMENT DELAY! PATIENT INFORMATION Patient: S.S.# Address:
More informationELECTION FORM California Region Group Plan
Senior Advantage Important information about this election form PLEASE READ ALL PAGES BEFORE SIGNING THIS ELECTION FORM Please type or print legibly, using a black or blue ballpoint pen, and press firmly.
More informationMedicare Resource Guide
Medicare Resource Guide Patient Name Dear Patient, Please take the time to read the following sections of this brochure as noted by your healthcare provider. These different components of Medicare deal
More informationPATIENT REGISTRATION FORM
Phone: 831-708-2919 Fax: 831-708-2937 PATIENT REGISTRATION FORM Who may we thank for referring you to us? Name (First, Mid Int. Last) Address City State Zip Code Home Phone w/ area code Email Cell Phone
More informationPediatric Ophthalmology Date: PLEASE PRINT: PATIENT NAME: Male: Female: AGE: First Middle Last BIRTH DATE: / / HOME PHONE: (
Eye Consultants of Atlanta, P.C. Scottish Rite Office 5445 Meridian Mark Road, Suite 220, Atlanta, GA 30342 Phone: (404-255-2419) - Fax (404-255-3101) Zane Pollard, M.D. Marc F. Greenberg, M.D. Mark A.
More informationMEDICARE ADVANTAGE INDIVIDUAL ENROLLMENT ELECTION FORM
MEDICARE ADVANTAGE INDIVIDUAL ENROLLMENT ELECTION FORM Please contact ONECare by Care1st Health Plan Arizona, Inc. (HMO) if you need information in another language or format (Braille). TO ENROLL IN ONECARE,
More informationCHAPTER 9 THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS
CHAPTER 9 THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS 9.0 -THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS DETERMINING OTHER HEALTH INSURANCE COVERAGE Behavioral health/integrated care providers
More informationIPhysician ID# ILanuage Preference ~ HEALTH INSURANCE ELECTION FORM MEDICARE. Page 1 of 4 for applicant to complete
ELECTION FORM Page 1 of 4 for applicant to complete PLEASE COMPLETE THE INFORMATION BELOW Last Name First Name IMiddle Initial Gender O M O F Permanent residence street address (Street Address ONLY - No
More informationPatient Information. Claims Address: Please also provide Health Insurance information in addition to Work Comp /Auto
For Office Use Updated By (Initial Here): Mailing Address: Patient Information City, State & Zip: Primary Home Cell Permission to Leave Messages: Yes No Secondary Home Cell Permission to Leave Messages:
More informationAbility to view, download, or print a "Continuity of Care Document" or "Health Summary".
The Salina Pediatric Care patient portal offers secure viewing and communication as a service to patients who wish to view parts of their records and communicate with our staff. This can be a valuable
More informationHOUSE OF REPRESENTATIVES 2252 TWENTY-EIGHTH LEGISLATURE, 2016 H.D. 1 STATE OF HAWAII A BILL FOR AN ACT
HOUSE OF REPRESENTATIVES 2252 TWENTY-EIGHTH LEGISLATURE, 2016 H.D. 1 STATE OF HAWAII A BILL FOR AN ACT RELATING TO DISCHARGE PLANNING. BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII: 1 SECTION
More informationHandbook for Home Health Agencies
Handbook for Home Health Agencies Chapter R-200 Policy and Procedures For Home Health Agencies Illinois Department of Public Aid CHAPTER R-200 Home Health Agency Services TABLE OF CONTENTS FOREWORD R-200
More informationAnthem Blue MedicareRx (PDP) Medicare Prescription Drug Plan Individual Enrollment Form 2016
Anthem Blue MedicareRx (PDP) Medicare Prescription Drug Plan Individual Enrollment Form 2016 Be sure to complete the entire enrollment form. Then, mail the completed form to P.O. Box 659403, San Antonio,
More informationWelcome to the LILETTA Patient Savings Program
Welcome to the LILETTA Patient Savings Program Eligible insured patients, activate your card today* * See full program Terms and Conditions on page 3 of this brochure or at LILETTAcard.com. Help With Your
More informationSeptember 15, 2009. <<First>> <<Last>> <<Address>> <<City>>, <<State>> <<Zip>> SUBJECT: CALPERS RETIREE HEALTH INSURANCE
C Office of Employer and Member Health Services P.O. Box 942714 Sacramento, CA 94229-2714 (888) CalPERS 225-7377 Telecommunications Device for the Deaf - 916-795-3240 FAX 916-795-1277 September 15, 2009
More informationHOW TO COMPLETE THIS FORM
HOW TO COMPLETE THIS FORM For your convenience, Sharp Health plan makes this reimbursement form available for your use. All requests for reimbursement received in writing shall be processed. 1. The Member
More informationWorkers Compensation Medicare Set-aside (WCMSA) Request & Worksheet
Workers Compensation Medicare Set-aside (WCMSA) Request & Worksheet Scope of Service If your workers compensation client is a Medicare beneficiary or has a reasonable expectation of being a Medicare beneficiary
More informationMEDICARE SUPPLEMENT APPLICATION - NEVADA Please complete entire application.
MEDICARE SUPPLEMENT APPLICATION - NEVADA Please complete entire application. Select a plan: Plan A Plan B Plan F Plan I Plan J Section 1 Applicant Information This complete original application will be
More informationMedicare Supplement Coverage Options
A Division of HealthNow New York Inc. An Independent Licensee of the BlueCross BlueShield Association. Medicare Supplement Coverage Options Thank you for your interest in our Medicare Supplemental coverage
More informationDavid A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX:
David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX: INSURANCE INFORMATION Did you injure yourself at work or is this injury a
More informationStreet Address Apt. or Post Office Box. City State Zip. Telephone Primary: ( ) Home Work Cell. Date of Birth / / Social Security # - -
Appointment Information Date: Time: Physician: Patient Information Name: First MI Last Street Address Apt. or Post Office Box City State Zip Telephone Primary: ( ) Home Work Cell Work: ( ) Cell: ( ) Date
More informationNj Victims of Crime Compensation Office
Nj Victims of Crime Compensation Office Claim Information and Application Instructions New Jersey has a Crime Victim s Compensation Fund to help with costs related to injuries received in a violent crime.
More informationFirst Name Middle Initial Last Name. Home Address. City State Zip. E-mail Date of Birth Sex: Male Female
800.334.1330 254.773.1330 fax 254.774.7652 4912 Midway Drive Post Office Box 6130 Temple, TX 76503-6130 www.carehealthplan.com A. PLEASE INDICATE WHICH PLAN YOU WISH TO ENROLL IN: Plan #4000 - Supplement
More informationMEDICAL BENEFITS CLASS ACTION SETTLEMENT NOTICE OF INTENT TO SUE
MEDICAL BENEFITS CLASS ACTION SETTLEMENT NOTICE OF INTENT TO SUE Complete this form if you are a MEDICAL BENEFITS SETTLEMENT CLASS MEMBER seeking to exercise a BACK END LITIGATION OPTION. In addition to
More informationPatient Billing. Questions/ Answers. Assistance Programs
Patient Billing Questions/ Answers Assistance Programs Table of Contents Patient billing: an introduction... 1 Patient financial responsibilities... 2 Our promise to you... 3 Frequently asked questions...
More informationPatient or Guardian Signature
Co Payment Policy According to the regulations of individual insurance carriers, patients are responsible for paying co payments at the time of each office visit. PAYMENT POLICY FOR SERVICES RENDERED If
More informationManaged Health Services Advantage MA Individual Enrollment Request Form
Managed Health Services Advantage MA Individual Enrollment Request Form Please contact Managed Health Services Advantage if you need information in another language or format (Braille). To Enroll In Managed
More informationCovered Person/Applicant Authorized Representative (please complete the Appointment of Authorized Representative section)
REQUEST FOR EXTERNAL REVIEW Instructions 1. If you are eligible and have completed the appeal process, you may request an external review of the denial by an External Review Organization (ERO). ERO reviews
More informationPATIENT INFORMATION EMERGENCY CONTACT LAST FIRST RELATIONSHIP REFERRAL SOURCE DOCTOR / REFERRING CLINICIAN: FAMILY MEMBER/FRIEND: INSURANCE:
PATIENT INFORMATION LAST FIRST MI GENDER M F BIRTHDATE MO./ DAY/ YEAR SS# - - ADDRESS CITY ST ZIP PHONE (CELL) PHONE (HOME) EMAIL MARITAL STATUS EMPLOYER ADDRESS OCCUPATION WORK PHONE EXT WHO IS YOUR PRIMARY
More informationUpdated as of 05/15/13-1 -
Updated as of 05/15/13-1 - GENERAL OFFICE POLICIES Thank you for choosing the Quiroz Adult Medicine Clinic, PA (QAMC) as your health care provider. The following general office policies are provided to
More informationTORT CLAIM FORM PACKET
TORT CLAIM FORM PACKET Please carefully read all of the information in this packet before completing and presenting your Tort Claim Form. Documents Contained in the Tort Claim Form Packet Instructions
More informationIMPORTANT INFORMATION Read all pages before signing this form
Kaiser Permanente Medicare Plus (Cost) GROUP/FEHB ENROLLMENT REQUEST FORM Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 2101 East Jefferson Street, Rockville, MD 20852 kp.org/medicare
More informationA PATIENT S GUIDE Understanding Your Healthcare Benefits
A PATIENT S GUIDE Understanding Your Healthcare Benefits This guide includes useful information about how health insurance works and the reimbursement process used to pay for treatments. TABLE OF CONTENTS
More informationCardiology Consultants of Atlanta, P.C. 2801 N. Decatur Rd. Suite 395, Decatur GA, 30033 (404) 298-2220 phone (678) 904-5336 fax
OFFICE POLICIES AND PROCEDURES Thank you for choosing Cardiology Consultants of Atlanta for your cardiovascular care. We realize that you have a choice in medical providers and are pleased that you have
More informationLILETTA Patient Savings Program
LILETTA Patient Savings Program Information and materials for your office and LILETTA patients Set up your office today by calling 855-706-4508 LILETTA Patient Savings Program Overview With the LILETTA
More informationHelp us process your applications faster
Help us process your applications faster Attach copies of your most current Household Income (patient and spouse) and Insurance cards with the MAP application. Accepted Proof of Income Documents: 1040,
More informationitems or information listed below and bring to your first visit:
ALAN L. WAGNER, M.D. F.A.C.S. DISEASES & SURGERY OF RETINA & VITREOUS MACULAR DEGENERATION DIABETIC RETINOPATHY RETINAL DETACHMENT ADULT & PEDIATRIC RETINAL SURGERY OCULAR ONCOLOGY / BRACHYTHERAPY INDOCYANINE
More informationReimbursement Guide 2011
Reimbursement Guide 2011 IMPORTANT SAFETY INFORMATION HYALGAN is indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to conservative
More informationPharmacy Handbook. Understanding Your Prescription Benefit
Pharmacy Handbook Understanding Your Prescription Benefit 1 Welcome to Your Prescription Drug Plan! Health Republic Insurance of New York has partnered with US Script to manage your prescription drug benefits.
More informationOptimum Performance Physical Therapy, LLC
Optimum Performance Physical Therapy, LLC Patient Information: Name: DOB: SS# Address: Phone: (H) (W) (C) Sex: Male Female Marital Status: M S D W Email: Employer Name/ Address: Referring Physician: (P)
More informationREGISTRATION FORM (Please print)
REGISTRATION FORM (Please print) PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not so,
More informationSAMPLE FSA KIT. Did you know that Flexible Spending Accounts can help you save on your health care and dependent care costs?
Did you know that Flexible Spending Accounts can help you save on your health care and dependent care costs? It s true! Having money in a Flexible Spending Account (FSA) is like having money in the bank
More informationLearning Objectives. What is a Billing Agent? Direct Payment to Providers
Learning Objectives Share basic Florida Medicaid policy regarding Billing Agents Improve compliance with Florida Medicaid policy Inform Billing Agents on how to access resources and assistance Developed
More informationIndividual Enrollment Request Form
Please contact Network Health Medicare Advantage plans if you need information in another language or format (Braille). To Enroll in a Network Health Medicare Advantage Plan, Please Provide the Following
More informationCigna Medicare Advantage HMO Plans 2016 Enrollment Request Form Please contact Cigna if you need information in another language or format (Braille).
Cigna Medicare Advantage HMO Plans 2016 Enrollment Request Form Please contact Cigna if you need information in another language or format (Braille). To Enroll in Cigna Preferred/Preferred Plus/Achieve
More information2012 STANDARD Medicare Supplement/ Life Insurance Plans
2012 STANDARD Medicare Supplement/ Life Insurance Plans Issued by Forethought Life Insurance Company ILLINOIS MS3000-01 IL 0112 2012 Forethought Standard Medicare Supplement Insurance Plans You can rely
More informationStonebridge Adult Medicine, P.A. Registration Form (Please Print)
Stonebridge Adult Medicine, P.A. Registration Form (Please Print) PATIENT INFORMATION Last Name: First Name: Is this your legal name? Yes No If not what is your legal name: Date of Birth: Sex: male female
More informationK L M N Basic, including 100% Part B coinsurance. Basic, including 100% Part B. coinsurance. Skilled Nursing Facility coinsurance.
Forethought Life Insurance Company Administrative Office P.O. Box 14659, Clearwater, FL 33766-4659 (877) 492-5870 Outline of Medicare Supplement Coverage Cover Page Benefit Plans A, C, F, G and N Benefit
More informationGuide. Astellas Pharma US, Inc. XTANDI Access Services SM 2015 NCCN Virtual Reimbursement Resource Room. NCCN.org/reimbursement
Astellas Pharma US, Inc. XTANDI Access Services SM 2015 NCCN Virtual Reimbursement Resource Room Guide The oncology reimbursement landscape continues to present ever-evolving challenges for clinicians
More informationCity of Portland HEALTH EXPENSE REIMBURSEMENT ACCOUNT
EXHIBIT C City of Portland HEALTH EXPENSE REIMBURSEMENT ACCOUNT S U M M A R Y P L A N D E S C R I P T I O N Effective January, 2016 City of Portland Health Expense Reimbursement Account Summary Plan Description
More informationTo Enroll in Capital Health Plan in 2015, Please Provide the Following Information:
Plan Use Only: Contract #: Group #: Member ID: Please contact Capital Health Plan if you need information in another language or format (Braille). To Enroll in Capital Health Plan in 2015, Please Provide
More informationPATIENT FINANCIAL RESPONSIBILITY STATEMENT
PATIENT FINANCIAL RESPONSIBILITY STATEMENT Thank you for choosing Medical Associates Clinic, P.C., as your healthcare provider. The medical services you seek imply an obligation on your part to ensure
More informationFinal. National Health Care Billing Audit Guidelines. as amended by. The American Association of Medical Audit Specialists (AAMAS)
Final National Health Care Billing Audit Guidelines as amended by The American Association of Medical Audit Specialists (AAMAS) May 1, 2009 Preface Billing audits serve as a check and balance to help ensure
More informationLAST Name: FIRST Name: Middle Initial 9 Mr. 9 Mrs. 9 Ms. Sex: 9 M 9 F
705 Mt. Auburn Street, Watertown, MA 02472 2015 HMO INDIVIDUAL ENROLLMENT FORM Please contact Tufts Health Plan Medicare Preferred if you need information in another language or format (Braille). To Enroll
More informationWellDyneRx Mail Service General Questions and Answers
WellDyneRx Mail Service General Questions and Answers I. Location/ Hours of Operation 1. Where is WellDyneRx Mail Pharmacy located? WellDyneRx mail pharmacy has two locations: 1) Centennial, CO, a suburb
More information