HP-1395 Coordination of Benefits Questionnaire 9-18 Fillable-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Member Name, Address, City, State, and Zip Code in the designated fields.
3. Fill in your Member ID Number accurately to ensure proper identification.
4. Indicate whether you or any family members have additional health coverage by checking 'Yes' or 'No' for Health Plan, Dental Plan, and Prescription Plan.
5. 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.
6. If applicable, provide information related to divorce decrees or child support orders that require health insurance coverage for dependents.
7. Finally, sign and date the form before submitting it via mail, fax, or email as instructed.

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