Insurance Information Form - Watkins Health Center

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I
I
nsurance
nformatIon
Please return the following information with a copy of both the front and back of your medical insurance card within 30 days.
Fax:
Email:
Mail:
whsbo@ku.edu
Watkins Health Center
Watkins Health Center
Attn: Business Office
Business Office
P
n
:
lease
ote
While Watkins Health Center allows this form
1-785-864-9502
1200 Schwegler Drive
to be submitted electronically, the security of
Phone: 1-785-864-9520
Lawrence, KS 66045
emailed health information cannot be guaranteed.
P
I
atIent
nformatIon
P
l
H
W
i
i
U
lace
abel
ere or
rite
n
f
navailable
Name ________________________________________
(printed)
KUID# _______________________________________
Patient Billing Address __________________________________________________________________________
City ________________________________________ State ________________ Zip Code __________________
P
I
olIcy
nformatIon
Insurance Company Name _______________________________________________________________________
Insurance Company Address ______________________________________________________________________
City ________________________________________ State ________________ Zip Code __________________
Does your insurance have a specific lab requirement?  No  Do not know  Yes — Please specify: ________________
Member ID# _____________________________________________________Group # ____________________
Policyholder Name ____________________________________________________________________________
Policyholder Date of Birth ____________________________________ Relationship _________________  Male  Female
(T
y
p
, G
S
)
ypically
our
arenT
uardian or
elf
Policyholder Street Address ______________________________________________________________________
City ________________________________________ State ________________ Zip Code __________________
First date of service to be billed ___________________
(d
o
a
p
S
y
W
l
B
T
T
i
c
)
aTe
f
ny
rior
erviceS
ou
ould
ike
illed
o
he
nSurance
ompany
– PLEASE NOTE –
1, You must contact your insurance company directly to determine how your specific plan processes and pays for services rendered
at Watkins Health Center.
2.
I
r
– If your insurance company requires pre-approval for services to be paid at Watkins Health Center, it
nsurance
eferral
is YOUR responsibility to provide that approval PRIOR to chargeable services being rendered. Unapproved charges will be
YOUR responsibility.
3. We DO NOT accept Medicare, Medicaid or plans underwritten by health insurance companies based outside of the United States.
Bo-101-1
W
h
S
aTkinS
ealTh
erviceS
08-19-15
T
u
k
he
niverSiTy of
anSaS

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