Arise Health Plan Other Insurance Questionnaire

ARISE HEALTH PLAN OTHER INSURANCE QUESTIONNAIRE

Member Name: ______Subscriber #: ______Date: ______

Do you, or any of your dependents covered by Arise Health Plan, have other medical coverage? Yes No Do you, or any of your dependents covered by Arise Health Plan, have other dental coverage? Yes No Do you, or any of your dependents covered by Arise Health Plan, have coverage through Medicare or Medicaid? Yes No If you answered “no” to all of the above questions, please sign and return in the enclosed envelope to: Arise Health Plan P.O. Box 11625 Green Bay, WI 54307-1625.

If you answered “yes” to any, or all, of the above questions, please complete the following for all coverages.

MEDICAL/DENTAL COVERAGE

Name of Planholder: ______SSN: ______DOB: ______Name of Insurance Carrier:______Phone: ______Address:______Group #: ______Effective Date: ______End Date: ______Type of Coverage: Family Single Type of Plan: Medical Dental Employer Name (If Employer Sponsored): ______Name of Individual (If Individual Coverage): ______Please list all participants on this plan. Attach a copy of any court orders, if applicable. Name: ______SSN: ______Court Ordered? ______Name: ______SSN: ______Court Ordered? ______Name: ______SSN: ______Court Ordered? ______*If there are additional dependents, please attach a separate sheet to this form.

MEDICARE/MEDICAID

Name of Person Covered: ______SSN: ______Medicare (HICN) Claim Number: ______Medicare Eligible Due To: Over Age 65 End-Stage Renal Disease Total Disability Effective Dates: Part A: ______Part B: ______Part C: ______Part D: ______End Dates: Part A: ______Part B: ______Part C: ______Part D: ______

Subscriber Signature: ______Date: ______

GEN-INS-0001 03-09