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HP-1395 Coordination of Benefits Questionnaire 9-18 Fillable-2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your Member Name, Address, City, State, and Zip Code in the designated fields.
- Fill in your Member ID Number accurately to ensure proper identification.
- Indicate whether you or any family members have additional health coverage by checking 'Yes' or 'No' for Health Plan, Dental Plan, and Prescription Plan.
- If you answered 'Yes' to any coverage type, complete all applicable fields regarding other insurance details including the name of the insurance company and effective dates.
- If applicable, provide information related to divorce decrees or child support orders that require health insurance coverage for dependents.
- Finally, sign and date the form before submitting it via mail, fax, or email as instructed.
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| Versions | Form popularity | Fillable & printable |
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| 2018 | 4.8 Satisfied (175 Votes) |
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