Coordination of Benefits

In order to properly coordinate your benefits, The Health Plan needs to determine if you or your family members have other health coverage. Accurate and complete information is required so that claims processing for your family will not be delayed.

If you do not have additional coverage, you still need to fill out this form.

Before we start, you will need your ID card from The Health Plan.

Please enter only your Member ID number (do not include the "H"), located on your insurance card. The last two digits of your ID number is found next to your name under the "Covered Individuals" tab.

^* Member HID:

Please enter your birthdate

^* Date of Birth:

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On the front of your postcard that you received in the mail, locate the Form ID in the bottom right corner and enter it below.

^* Form ID: