Medex subscriber claim form 2025

1. Click ‘Get Form’ to open the Medex Subscriber Claim Form in the editor.
2. Begin by entering your Medex Identification Number, which can be found on your Medex ID Card. Ensure this is accurate for processing.
3. In Part I, fill in your last name, first name, middle initial, and Medicare Health Insurance Claim Number. Provide your complete street address, city, state, and zip code.
4. Complete Part II by entering your date of birth in MM/DD/YYYY format and select your gender. Additionally, provide details of your most recent hospitalization including the hospital's name and address along with admission and discharge dates.
5. In Part III, list the type of service received, provider's name and address, diagnosis or illness, date of service (in MO/DAY/YR format), and amount charged for each service. Attach itemized bills as required.
6. Part IV requires you to indicate the total number of bills attached and total charges. Choose whether payment should be made to you or directly to the provider.
7. Finally, sign and date the form in the designated area to certify that all information is correct before submitting it as instructed.

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