Coordination of Benefits - Summary

Please update or confirm the information we have on file for you and your eligible family members. Correct information helps us process your claims accurately and efficiently.

To Update
If you have new coverage information to add or update for any member(s), check the box next to the member(s). Then click Update.

To Confirm
If the data displayed below is still current, click Confirm.

Coordination of Benefits

Name		Relation		Date of Birth		Medicare			*Group Coverage
							Effective		Last Verified Date	Status
Chris Johnson	Self	01/01/1965	Part A: Ineligible		01/01/2008	Not Applicable
			Part B: Ineligible
			Part D: Ineligible
Pat Johnson	Spouse	01/01/1964	Part A: Ineligible		01/01/2008	Not Covered by Other Insurance
			Part B: Ineligible
			Part D: Ineligible
Madison Johnson	Child	05/01/2000	Part A: Ineligible		01/01/2008	Not Applicable
			Part B: Ineligible
			Part D: Ineligible

* Coverage obtained privately on an individual basis, including government-sponsored plans (such as Champus, CHIP, and Medicaid) are not considered Group Coverage and should not be reported here.

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