Care first form 2012-2019: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin by entering your Member ID# in field 1, followed by the Group Number or Enrollment Code in field 2. Ensure accuracy to avoid processing delays.
Fill out the Patient’s Name (field 3), Date of Birth (field 4), and Sex (field 5). Select the appropriate relationship to subscriber in field 6.
Provide the Subscriber’s Address in field 9 and indicate if there is other health insurance coverage in field 10. If yes, include the name of the other insurance company.
Complete fields regarding employment status and any accidents related to the patient’s condition. Be thorough as this information is crucial for claims processing.
List all charges being claimed in section 16, ensuring you attach original itemized bills from providers for these services.
Finally, sign and date the form at the bottom to authorize benefits assignment before submitting your claim.

Start using our platform today for free to streamline your claims process!

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