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  Coordination of Benefits

Coordination of Benefits: Medicare Status

You have indicated you wish to update Medicare information. Please answer all questions on this page as accurately as possible about yourself or your family member to let us know about your eligibility and current enrollment status. This will help us better process any future claims.

Coordination of Benefits

Name:

 Pat Johnson

Relationship to Subscriber:

Spouse

Date of Birth:

02/12/2006

1. Please indicate your current Medicare Eligibility status:

 

Eligible and enrolled in some or all Parts (A, B, D)

Eligible but not enrolled in any Parts (A, B, and D)

Ineligible for Part A only

Ineligible for Part B only

Ineligible for both Part A and Part B

Currently not entitled to receive any Medicare benefits

2. If Eligible for one or more Medicare Parts, please select the reason that best describes your eligibility. If you are unsure, click "Not Sure".

 

65 years and over

Kidney Disease

Disabled

Disabled but actively at work

Not sure

3. Please indicate your current Medicare Participation status: (One selection for each Part is required.)

Enrolled Effective Date Cancellation Date Not Enrolled
Part A
Part A
Part B
Part B
Part D
Part D

Please enter the date you would have been eligible even if you chose not to, or did not yet enroll. (Optional.)

Entitlement Date:


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Today's Date: Jun 5, 2006©2006 UnitedHealthcare