When you or family members have health insurance through more than one company, benefits must be coo 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section I: Subscriber Information. Fill in your name, QualChoice ID number, and contact phone number. If you or any family member is covered by another health plan or Medicare, select 'Yes' and proceed to the appropriate section.
3. If you answered 'Yes' for another health plan, complete Section II. Provide details about the other health plan including its name, phone number, address, and member ID number. Attach a copy of the other insurance ID card.
4. List all family members covered by the other health plan along with their relationship to you. If applicable, indicate if there is a court order for dependent coverage.
5. For Medicare coverage, complete Section III by attaching a copy of your Medicare ID card and listing all family members covered by Medicare.
6. In Section IV, sign and date the form to confirm accuracy. Finally, follow Section V instructions to return the form via fax or mail.

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