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Human Resources

Coordination of Benefits Form For
Other Medical Coverage on your Dependents

If  your spouse or dependents 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 own additional medical coverage please visit:
Other Medical Coverage On You

If you, your spouse or dependents do not have other medical coverage, you do not need to complete the form.

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)

Employee Information:

SSN#:

Last Name:

First Name:

MI:

Dependent Information:

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

They are not covered by any other medical plan.
They are covered by another medical plan through the University of Cincinnati:
HMO PPO CMP
Under employee (name):

Last Name:

First Name:

Under employee SSN#:

They are covered by Medicare
Part A (hospital) Part B (medical) Parts A & B

Medicare Covered Dependent's Name:

Last Name:

First Name:

Medicare Identification Number:
(9 numbers & a letter)

Medicare Covered Dependent's Name:

Last Name:

First Name:

Medicare Identification Number:
(9 numbers & a letter)
They are covered by another medical plan:
as an employee as a dependent as a retiree

Dependent's Last Name:

First Name:

Subscriber Last Name:

First Name:

Identification #:

Employer's Name:

Insurance Company Name:
Additional Dependent - covered by another medical plan:
as an employee as a dependent as a retiree

Dependent Last Name:

 First 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:

Additional Dependents: If you have additional Dependents, please submit the current page before visiting the following link: Additional Dependents.  You must submit both the current page as well as the Additional Dependents page to update your records.

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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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