Google fax cover sheet 2025

1. Click ‘Get Form’ to open the Google Fax Cover Sheet in the editor.
2. Begin by filling out the 'Subscriber/Employee Information' section. Enter your Subscriber/Member number, phone number, last name, first name, and home address including city, state, and zip code.
3. Next, provide details for the 'Patient Information' section. Include the patient's last name, first name, sex, relationship to subscriber, and school information if applicable.
4. In the 'Accident Information' section, indicate whether it was a work or auto accident. If yes, describe how it occurred and provide the date of the accident.
5. Complete the 'Other Insurance' section if applicable. Indicate if the patient has other insurance coverage and provide necessary details such as policy number and insurance carrier.
6. Sign and date at the bottom of the form under 'Member Signature' and 'Assignment of Benefits' if you wish for benefits to be paid directly to your provider.

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