SERGEANTS BENEVOLENT ASSOCIATION
SERGEANTS BENEVOLENT ASSOCIATION
35 Worth Street New York, NY 10013 212-431-6555 (Phone) / 212-431-6487 (Fax)
CATASTROPHIC COVERAGE BENEFIT CLAIM FORM INSTRUCTION INFORMATION
Once you have met the $2000.00 deductible, complete the attached SBA Catastrophic Coverage Claim Form. Submit the completed form together with copies of all health plan "Explanation of Benefit" (EOB) forms (including any Coordination of Benefits EOBs), Current Procedural Terminology (CPT) codes (if not included on EOB), and paid bills/canceled checks to the SBA Fund office in a timely manner. Please notify the SBA Fund office if there is a delay in submitting the claim. A separate claim form must be filed for each eligible dependent. This is a reimbursement benefit. Members are responsible for payment to their medical providers.
COORDINATION OF BENEFITS
The SBA Catastrophic Coverage Benefit was designed to assist our Members meet the cost of financially distressing illness, injury or disease. Since it is not intended that any member receive greater benefits than the actual incurred covered expenses, the amount of benefits paid will be coordinated with the benefits of any other Plan to which the Member or eligible dependent is entitled to receive benefits.
EXCLUDED EXPENSES
a. This benefit does not cover prescription drugs, workers compensation benefit claims, occupational injury, illness or disease, dental work, cosmetic surgery, fertility treatments, transportation, no fault auto insurance medical expenses, experimental procedures, any medical, surgical or hospital service/charge not approved for payment by a Member's Participating Provider Organization (PPO) or Point of Service Plan (POS).
b. Services and supplies that are unreasonably priced or that are not reasonably necessary for treatment of an injury, illness or disease.
c. Expenses caused or services not ordered by a physician or surgeon who is a Doctor of Medicine (M.D.) and duly licensed to practice medicine.
SERGEANTS BENEVOLENT ASSOCIATION
35 Worth Street New York, NY 10013 212-431-6555 (Phone) / 212-431-6487 (Fax)
SBA CATASTROPHIC COVERAGE CLAIM FORM
MEMBER'S INFORMATION
NAME: FIRST _____________________________________________________________________ MI _________________________ LAST _____________________________________________________________
MAILING ADDRESS: STREET __________________________________________________________ CITY _________________________________________ STATE_________ ZIP____________
TAX ID#: ______ ______ ______ ______ ______ ______
PHONE NUMBER: _________-__________-_____________________
PATIENT'S INFORMATION
NAME: FIRST _____________________________________________________________________ MI _________________________ LAST _____________________________________________________________ MAILING ADDRESS (If different from above):
STREET ______________________________________________________________________ CITY ________________________________________________ STATE______________ ZIP________________________
DATE OF BIRTH: _______/________/__________ SOCIAL SECURITY #: _______-______-________ RELATIONSHIP: _______________ CATASTROPHIC INFORMATION
DIAGNOSIS: ______________________________________________________________________________________________________________
HAS THE SBA HEALTH & WELFARE FUND EVER PAID A CATASTROPHIC COVERAGE CLAIM FOR THIS
PATIENT? (CIRCLE ONE):
YES
NO
AMOUNT OF BENEFIT PAID: $ _____________________________
YEAR OF PAYMENT: ________________________
HEALTH COVERAGE INFORMATION
MEMBER'S NYC HEALTH PLAN: _____________________________ HEALTH PLAN ID #: _______________________________
IS THE PATIENT COVERED BY ANY OTHER HEALTH INSURANCE PLAN? (CIRCLE ONE): YES
NO
IF "YES", PLEASE PROVIDE THE FOLLOWING INFORMATION:
OTHER INSURED'S NAME: FIRST __________________________________________________ MI ____________ LAST ___________________________________________________________
OTHER INSURANCE PLAN NAME: ________________________________ OTHER HEALTH PLAN ID #: _________________
THE FOLLOWING DOCUMENTS/INFORMATION MUST ACCOMPANY THIS FORM: ALL HEALTH PLAN EXPLANATION OF BENEFIT (EOB) FORMS, CPT CODES (IF NOT INCLUDED ON EOB) AND COPIES OF PAID BILLS/CANCELLED CHECKS.
MEMBER'S SIGNATURE
I DO HEREBY STATE THAT ALL THE INFORMATION I HAVE ENTERED ABOVE IS CORRECT.
MEMBER'S SIGNATURE: ____________________________________________________________ DATE: _________________________
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