Provider OHC Referral Form

Other Health Coverage (OHC) Referral Form
Coordination of Benefits (COB)

Please provide the following information and click Submit Form at the bottom of this page.

Date Submitted to
COB Specialist:*

Thank you for using the Trial Version of Telerik UI for ASP.NET AJAX to build more powerful applications faster. Purchase the Commercial Version now to get access to all product updates and the Telerik expert support.

Open the calendar popup. Thank you for using the Trial Version of Telerik UI for ASP.NET AJAX to build more powerful applications faster. Purchase the Commercial Version now to get access to all product updates and the Telerik expert support.

Submitted By:

First Name:*

Last Name:*

Provider Office:*

Provider Return Contact Phone:*
(XXX-XXX-XXXX)

Provider Return Contact E-mail:*

Member's Name (For whom you are requesting a change):*

Member's Alliance ID #:*

CCN #:

Date of Service:

Policy Holder Relationship to Member:

Policy Holder Name (As it appears on Alliance ID Card):*

Policy Holder's SSN:
(XXX-XX-XXXX)

Policy Holder's Date of Birth:

OHC Carrier Name:*

OHC Policy ID #:*

OHC Employer Name:*

OHC Group Number:*

OHC Phone:*
(XXX-XXX-XXXX)

OHC Effective Date:

OHC End Date:

Does this insurance carrier use a Third Party Administrator (TPA)?*

YesNo

TPA Name:*
TPA Phone:* (XXX-XXX-XXXX)
TPA Member ID #:*

Do you have proof of terminated coverage? (If Yes, email proof of OHC to [email protected].)	YesNo
Additional Comments / Remarks:	Enter text here... (750 characters max) 0/750
Contact a COB Specialist, with any questions via secure email at [email protected].

Other Health Coverage (OHC) Referral FormCoordination of Benefits (COB)

Other Health Coverage (OHC) Referral Form
Coordination of Benefits (COB)