Insurance Claim Form
| Medical Benefits Questionnaire |
Date: |
| Part A - Patient |
|
|
Is the Patient also the Insured? Yes No |
Is there other insurance? Yes NO |
| Patient's Name: |
|
DOB: |
| Patient's Address: |
Phone: |
| |
Fax: |
| City: State: |
Zip: |
| e-mail address: |
Patient Status: ◊ Single ◊ Married
◊ Other |
◊ Employed
◊ Full or ◊ Part Time Student |
| Patient's Relationship to Insured: ◊ Self ◊ Spouse ◊ Child ◊ Other |
| |
|
| Part B |
|
| Insured's ID Number: |
Group Name/Number:: |
| Employer's Name: |
Insurance Plan: |
| Doctor's Name: |
Doctor's Phone #: |
| Is the patient also the insured? YES NO |
Doctor's Fax: |
| (Skip Part C below if Insured and Patient are Same) |
| Part C |
|
| Insured's Name: |
Phone#: |
| Insured's Address: |
Fax: |
| City: State: |
Zip: |
| |
|
| Date of start of current: |
◊ Illness or ◊ Injury |
| Diagnosis: |
|
Return to:
Fergus Affiliates, LLC dba ElderStore/BoomerStore & UroAnswers
6820 Meadowridge Court, Suite A-9, Alpharetta, GA 30005
888-833-8875
Fax: 770-844-2153
attach to e-mail: insurance@elderstore.com