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Human Resources

Coordination of Benefits Form For Other Medical Coverage 

If you are covered by any other medical coverage (including other UC  coverage or Medicare), you must complete the Coordination of Benefits Form below. 

To provide information on your dependents,  ( spouse and children), please visit: Other Medical Coverage on your Dependents

This is an online form; completing and submitting it will result in the requested change. By typing in your name in the Employee Signature field, you are authorizing a change in your records. If you wish to retain a copy of the completed form, please print a copy before submitting it.  For questions email HR .

Date:(mmddyy)

SSN#:

Last Name:

First Name:

MI:

Please put an "X" in applicable boxes, and complete any additional information requested.

I am not covered by any other medical plan.
I am covered by another medical plan through the University of Cincinnati:
HMO POS CMP 1st 1000
Under employee (name):

Last Name:

First Name:

Under employee SSN#:

I am covered by Medicare
Part A (hospital) Part B (medical) Parts A & B

Medicare Identification Number:
(9 numbers & a letter)
I am covered by another medical plan:
as an employee as a dependent as a retiree
Under Subscriber (name):

Subscriber Last Name:

First Name:

Identification #:

Employer's Name:

Insurance Company Name:

Authorization

By typing in your name in the Employee Signature field, you are authorizing a change in your records.

I certify the information I have furnished on this form is true, correct and complete to the best of my knowledge. Furthermore, I understand the information I supplied may be audited by the University and/or representatives. I understand that falsifying documents may be grounds for disciplinary action up to and including termination of employment. In addition, I may be in violation of federal and/or state laws and subject to prosecution.

Employee Signature:



 

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Human Resources
University Hall · 51 Goodman Drive · University of Cincinnati
PO Box 210039 · Cincinnati, OH 45221-0039 · (513)556-6381
Send comments or questions to: Human Resources

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