Coordination of Benefits (COB) Questionnaire

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If you or your dependents are covered by more than one health plan, print out this form, fill it out, and mail it to HMSA at the address below.

To avoid delays, please follow the instructions carefully and make sure the information you provide is complete.

At the top of the form, indicate what type of coverage you, your spouse, and your dependents have.

Section 1. HMSA subscribers must fill in their name, birth date, employment status, date of retirement (if retired), HMSA subscriber ID number (printed on your HMSA membership card), Social Security number, and phone number. Sign and date the form.

Section 2 - Other Coverage Information. Policyholders of the other health plan must fill in their name, sex, birth date, Social Security number, and relationship to the HMSA subscriber. Include the other health plan’s name, address, and phone number. Indicate the policyholder’s identification number, employment status, employer, and date of retirement (if retired).

Indicate the type of coverage the policyholder has and the effective date and cancellation date.

List the names of other dependents covered by the other plan and their relationship to you.

Section 3 - Medicare Coverage Information. List the name, Social Security number, and Medicare number of the Medicare beneficiary. To indicate the type of coverage, include the effective date and reason for Medicare eligibility. If you check "End-Stage Renal Disease," indicate the initial dialysis date.

Mail the questionnaire to:
HMSA
P.O. Box 860
Honolulu, HI 96808-0860
Attn.: Claims Administration COB, 7th Floor