Summary of Coordination of Benefits

Please take a moment to review your Coordination of Benefits information currently on file for you and your eligible family members. Accurate information helps us better process your claims and reduce your plan costs. So, about once a year, we ask you to verify your data or update us with any new information you may have.

If your data displayed below is still current, please simply click the CONFIRM button. If you have any new coverage information, please check off the member(s) of your family needing updates and click UPDATE. We'll then ask you a few questions to get all your information up to date.

Coordination of Benefits

Name		Relation		Date of Birth		Medicare				*Group Coverage
							Effective	Cancellation		Last Verified Date	Status
Chris Johnson	Self	02/22/06	Part A:	12/23/1999	12/23/2005	02/15/2006	Not Applicable
			Part B:
			Part D:
Pat Johnson	Child	02/12/06	Part A:	12/23/1999	12/23/2005	02/15/2006	Not Covered by Other Insurance
			Part B:
			Part D:

* Coverage obtained privately on an individual basis, including government-sponsored plans (such as Champus, CHIP, and Medicaid) are not considered Group Coverage and should not be reported here.

Update

Confirm