Text Size: AAA

COB Questionnaire Form

Your Blue Cross and Blue Shield contract contains a Coordination of Benefits (COB) provision. This form is required by Blue Cross and Blue Shield in order for us to process your claims accurately. If you have any additional questions regarding this questionnaire or if the information below changes, please call the number found on the back of the identification card. We appreciate your prompt reply.

BCBS Policy Holder Name:
BCBS Group #:
BCBS Member ID#:
Alpha Prefix #:


OTHER INSURANCE:
Are you or any other member of this Blue Cross and Blue Shield policy covered by another medical or dental insurance policy or any other Blue Cross and Blue Shield policy?

No If No, please complete Section D, print, sign, date and return this questionnaire to Blue Cross and Blue Shield of Texas, P.O. Box 660044, Dallas, TX 75266-0044, indicating "No other insurance."

Yes If Yes, please complete all the fields below that pertain to the member(s) that has the other Coverage, print and return to Blue Cross and Blue Shield of Texas, P.O. Box 660044, Dallas, TX 75266-0044.

Section A
Name(s) of Dependent(s) on BCBS Policy
Name




Relationship




DOB



Sex
Social Security # (Optional)

No Dependent(s) on BCBS Policy
Section B If this does not apply, skip to Section C.
Check those that apply: Other Health Insurance
Other Dental Insurane
What type of policy is this? Group
Individual Policy
Student Poloicy
Medicare Supplemental
Other Insurance Carrier's Name:
Address:
City:
State:
Zip:
Phone Number:

Dependent(s) listed on the other insurance

Effective or Cancel Date, if different from policyholder:
Other Insurance Policyholder’s Name:
Policyholder’s Date of Birth:

ID#

Effective Date of Other Insurance:

If Cancelled, Cancellation Date:
Is the policyholder:

Actively working for the group
Inactive
Retired, retirement date
on COBRA, which began

Policyholder's Employer:
Employer's Address:
City:
State:
Zip:
Section C If this does not apply, skip to Section D.
Medicare Information
Do the policyholder and/or dependent(s) have Medicare? Yes No
Name of person(s) with Medicare:
Medicare Number, including alpha character(s):
Effective Date of Medicare Part A:
Effective date of Medicare Part B:
Effective date of Medicare Part C:
Effective date of Medicare Part D: 
Medicare Entitlement: Age
Disability *
End Stage Renal Disease (ESRD)
*If the reason is for Disability or ESRD, please provide the following:

1st Date of Disability:
1st Date of Dialysis for ESRD:
Was ESRD started in a facility?
Yes No
Was ESRD started as Self Dialysis or Home Dialysis:
Yes No
Has a transplant been performed? Yes No
If yes, please provide the date of the transplant.
In addition, please provide a copy of the Medicare Card
Section D

Court Order Information

Is there a Court Order specifying a person(s) who must maintain health coverage for any of your dependent(s)?

 Yes No
List the name(s) of the dependent(s) to whom the Court Order applies:
If yes, who is the person(s) listed to maintain health coverage?
What is the relation to the child(ren)?
Who has custody of the child(ren) more than 50% of the time?

Documentation of the court order may be requested from your Blue Cross Blue Shield plan