Use this form to begin the processing of the bills for your medical event. Only one NNF is needed per medical event.
Providers should be directed to send their bills directly to the processing center on
form UB-04 for hospitals or CMS 1500 for other providers.
**Please fill out this form completely; as an incomplete form
may delay sharing. If you need assistance, call Member Services at
(800) 264-2562.**
You should only fill out this form for a new medical event, there is no
need to submit for a subsequent visit related to the same medical event.
However, you may want to submit this medical bill for sharing solely for
the purpose of obtaining a discount. In that case, please complete this
form, answering yes to the question below, but be aware if the bill is not
eligible for sharing, it will not be applied to your AHP or IMR.
Are you submitting this form only for the purpose of a possible discount?
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Section II
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- Is the patient an adult child?
If yes, please fill out the Adult Dependent Eligibility Form and describe below the circumstances of illness or accident.
- Is there insurance or any other resource available to pay all or part of the
medical bills, such as workers' compensation, property owner's liability
insurance, health insurance, foundations, service organizations, or governmental
programs?
If yes, list the insurance and/or other resource name(s), policy number(s)
and phone:
If your answer is yes, please fax the following documentation to: (321) 722-5138.
A) Copy of your benefit plan and insurance card.
B) Documentation of the effective date (and term date, if any) of this benefit.
C) The names of the family members who are covered.
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Is any family member eligible for Medicare or Medicaid?
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If your answer is yes, please fax the following documentation to: (321) 722-5138.
A) Copy of your Medicare or Medicaid card.
B) Documentation of the effective date (and term date, if any) of this benefit.
C) The names of the family members who are covered.
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Section III
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- Please select the type of medical event from the list
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**Penalties may apply if you choose to utilize a non-PHCS provider.
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Section IV
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Have you paid any amount to providers for
this medical event?
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Remember: Payment up front is not required. Please use the
Reimbursement form found online at www.MyChristianCare.org
to document any out of pocket expenses (not your provider fee).
Initial Member Responsibilities and Annual Household Portions are applied at the time the bill is processed, not the date of service.
If yes, then please provide Date of Service,
Provider Name, Provider Phone Number, and Amount Paid:
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