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MEDICAL CLAIM FORM ELECTRICAL WELFARE TRUST FUND - page 1 / 2

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ADDITIONAL FORMS: (301) 731-1064 Have your Social Security Number ready.

PART A Member Information

The Eligible Electrical Worker’s Social Security Number:

//

______ ______ ______

PART B Patient Information

Definition of a Dependent:

Your lawful spouse that resides with you, and any unmarried children who are fully dependent on you for support and maintenance. For more information about dependents see the plan booklet.

PART C Authorizations

Assignment of Benefits

MEDICAL CLAIM FORM ELECTRICAL WELFARE TRUST FUND

4601 Presidents Drive - Suite 300 - Lanham, MD 20706-4832 Fax: 301-731-1065 • info@ewtf.org IMPORTANT: Claims MUST be filed within one year or they will be denied. Attach provider’s insurance form (i.e., superbill, HCFA form)

INQUIRIES PHONE: (301) 731-1050 Have all papers available when you call.

THIS SIDE MUST BE COMPLETED BY THE MEMBER

Member Name

________________________________________________________________________________

Last

First

Initial

Home Address

_______________________________________________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Home Phone

Work Phone

___________________________________

_________________________________

Email address

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Member DOB _____/_____/_____

Employer

__________________________________________________

Marital Status

circle one:

Married

Single

Separated Divorced Widowed

Patient Name

___________________________________

Birthdate

Marital Status

_____/_____/_____

___________________

Relationship to Member

_____________________(If child over 19, full-time student? circle one: Yes

No)

Patient address

______________________________________________________________________________

Does patient have other health coverage?

Circle one: Yes

No

If yes, identify:

___________________________________________________________________________________

Attach copy of EOB Telephone Number

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Is patient covered under Medicare?

Circle one: Yes

No

If yes, attach Medicare Explanation of Benefits from carrier.

I verify that all information contained in this form is true, correct and complete to the best of my knowledge.

I authorize any licensed doctor, practitioner of the healing arts, hospital, clinic, health related facility, pharmacy, government agency, insurance company, group policyholder, employee or benefit plan administrator having information as to the care, advice, treatment, diagnosis or prognosis of any physical or mental condition, or the financial or employment status of the participant named below, to provide this information to the Electrical Welfare Trust Fund.

Under the privacy provisions of the Health Insurance Portability and Accountability Act of 1996, you may be required to complete a separate Authorization Form, or Personal Representative Form (in the case of

a non-spousal representative).

PRINT NAME

DATE

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_____________

S i g n a t u r e o f P a r t i c i p a n t / G u a r d i a n _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Is payment to be made directly to Provider

____YES

____

NO

If provider of service shows assignment and balance due, payment will be made to provider. If no assignment is checked, payment will be made to provider.

If your claim is the result of an accident or injury, fully complete the back of this form.

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