Free 51309.FH11 - Indiana

PRIVATE MEDICAL INSURANCE SUPPLEMENT
State Form 51309 (R3 / 1-09) / BCD 0086

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Division of Disability and Rehabilitative Services

Effective February 01, 2009. To be completed for all children who are covered by private health insurance. Attach a copy of the front and back of the insurance card.
Name of child (last, first, middle initial) Child ID Name of Service Coordinator Telephone number Date of birth (month, day, year) County Fax number

(
Name of insurance carrier Date coverage started (month, day, year) Group name Group number Policy / member ID

)
INSURANCE INFORMATION

(

)

Date coverage ended (month, day, year)

If the plan has a GROUP number, you must have a member number / ID. You may or may not have a Group name. If the plan has a POLICY ID, you may or may not have a group name or number

Policy billing order (check one, please complete an additional form for a secondary insurance)

Primary

Secondary

Tertiary

Unknown Individual Policy Medicaid Personal Personal Payment (cash - no insurance) Point of Service Preferred Provider Organization (PPO) Other: As indicated on page two (2) of this form POLICY HOLDER INFORMATION (family subscriber)
Telephone number Employee Retirement Income Security Act (ERISA) (MUST CHECK ONE)

Type of insurance (MUST CHOOSE AT LEAST ONE)

Consolidated Omnibus Budget Reconciliation Act (COBRA) Disability Disability Benefits Exclusive Provider Organization Group Policy Health Maintenance Organization (HMO)
Name of policy holder (last, first, middle initial) Relationship to child (check one)

ERISA or Self-Insured Non-ERISA or Fully Insured Exceptions (State or University Employee)

(
Father Mother Stepfather Stepmother Other:

)

Employer tax ID

Address (number and street) City Date of birth (month, day, year) State ZIP code Social Security number of policy holder

The information I have provided is complete and correct to the best of my knowledge. I will notify the First Steps Service Coordinator if there are any changes in my insurance or insurance coverage.
Signature of parent Date (month, day, year)

Signature of Intake / Service Coordinator

Date (month, day, year)

DISTRIBUTION:

Original - SPOE EI file; Copy - Parent, Service Coordinator

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COMPLETE LISTING FOR TYPE OF INSURANCE: If OTHER is checked on the front page of this form, please indicate which insurance type applies toward coverage. Medicare Secondary, End-Stage Renal Disease Beneficiary in the 12 month coordination period Medicare Secondary, Working Aged Beneficiary or Spouse with Employer Group Health Plan Medicare Secondary, No-fault Insurance including Auto is Primary Medicare Secondary, Workers Compensation Medicare Secondary, Public Health Service (PHS) or other Federal Agency Medicare Secondary, Black Lung Medicare Secondary, Veterans Administration Medicare Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) Medicare Secondary, Other Liability Insurance is Primary Auto Insurance Policy Commercial Medicare Conditionally Primary Health Maintenance Organization (HMO) - Medicare Risk Special Low Income Medicare Beneficiary Indemnity Long Term Care Long Term Policy Life Insurance Litigation Medicare Part A Medicare Part B Medigap Part A Medigap Part B Medicare Primary Other Property Insurance - Personal Qualified Medicare Beneficiary Property Insurance - Real Supplemental Policy Tax Equity Fiscal Responsibility Act (TEFRA) Workers Compensation Wrap Up Policy

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