2015 BridgeSpan Direct Member Reimbursement Form

BridgeSpan Health Company
2890 E. Cottonwood Parkway
Salt Lake City, UT 84121-7089
DIRECT MEMBER REIMBURSEMENT FORM
Thank you for choosing us for your health insurance coverage. Use this claim form for any reimbursement requests you may have. If you
received services from a participating provider, your claim should be submitted by the provider; therefore, you do not need to submit this
form unless you know that your claim was not submitted. Please complete a separate form for each family member, pharmacy or provider
(print additional copies of page 2 if necessary). For claim filing time limits, review your benefit information.
1.
2.
3.
4.
5.
Complete the information below and where indicated on the following page.
Write your ID number on the top of each page.
Tape your original receipts in the boxes marked for receipts; cash register receipts will not be accepted.
Retain copies of receipts for your records. Receipts will not be returned.
Sign the completed form where indicated at the bottom of this page and mail to:
BridgeSpan Health Company
PO Box 1106
Lewiston, Idaho 83501
MEMBER INFORMATION
Patient's Name (Last, First, M.I.)
Patient's Date of Birth
Patient's Sex
(mm/dd/yyyy)
Policyholder's Name (Last, First, M.I.)
Male
Female
Patient's Relationship to Policyholder
Self
Policyholder's Street Address
City
State
Dependent
Telephone Number
xxxxx-xxxx
State
Patient's ID Number
Spouse
ZIP Code
Group Name
(xxx) xxx-xxxx
Group Number
OTHER INSURANCE INFORMATION
Are you or ANY family members on this policy covered by other:
Medical coverage?
Yes
No
Dental coverage?
Yes
No
Prescription Coverage?
Yes
No
If YES, is this coverage
Group
Individual
Are you or any family members covered by Medicare?
Vision Coverage?
With Orthodontia?
Yes
No
Yes
Yes
If YES:
No
No
Part A
Part B
Part D
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS "YES," please complete the section regarding the other insurance.
If there are more than one additional policy, attach the requested information for each policy on a separate sheet of paper.
Name of Other Insurance
Subscriber's Name
ID Number
Date of Birth
(mm/dd/yyyy)
Street Address for Submitting Claims
City
Subscriber's Relationship to
BridgeSpan Policyholder
State
ZIP Code
State xxxxx-xxxx
This other insurance covers:
BridgeSpan Policyholder's Spouse
If covered children are from divorced parents, indicate name of person with legal custody
BridgeSpan Policyholder
Dependents
Name of Subscriber's Employer
Effective Date of this Plan
Active
Retiree
(mm/dd/yyyy)
Please indicate why the patient paid in cash
I certify that the above statements are correct and hereby authorize any physician, dentist, hospital, employer, union, insurance company,
or prepayment organization to supply my employer and its agents any information required in connection with this claim. A photocopy of
this authorization shall be as valid as the original.
(mm/dd/yyyy)
ASignature (Subscriber or Patient)
FORM PD025-BSP Page 1 of 2 (Rev. 11/15)
Date
Prescription (Rx) receipts must contain:
Rx Number
Date Rx was filled
Provider's Name
Drug Name and NDC Number
Quantity and days supply
Charge
Medical, Dental and Vision receipts must contain:
Provider's Name and Address
National Provider Identifier
Diagnosis and Procedure Codes
Date of Service
Itemized Charges
Contact the provider or pharmacy if you need additional information
Nature of Illness or Injury
TAPE RECEIPT HERE
In date order
Doctor's Name (If not on receipt)
(mm/dd/yyyy)
If Injury, Date Occurred
How, When, Where
Nature of Illness or Injury
TAPE RECEIPT HERE
In date order
Doctor's Name (If not on receipt)
(mm/dd/yyyy)
If Injury, Date Occurred
How, When, Where
FORM PD025-BSP Page 2 of 2 (Rev. 11/15)