Other Party Liability

Patient Information Form

BCBSKS Member's Name
 First MI Last
Member ID Number
Patient's Name
 First MI Last
Annually, Blue Cross and Blue Shield of Kansas verifies whether or not our members have duplicate coverage.
If it has been a year since the patient's last visit to this provider, please answer the following:
Is the member, or any family member, enrolled in other health insurance (not Medicare, SRS/Medicaid) for medical or dental expenses? Yes No
We also attempt to verify if injuries, carpel tunnel, heart attacks, hernias and back problems are eligible to be covered by worker's compensation or auto insurance. If the visit is related to an injury or one of the conditions described above, please answer the following questions unless this is a follow-up visit and this form has been filled out previously.
    Date of accident or onset of symptoms:  (mm/dd/yyyy)
Coordinating benefits places responsibility with the proper carrier, which helps keep rates lower for our customers.