ISO: Pre-existing Conditions

HEALTH INSURANCE RESPONSE FORM – PRE-EXISTING CONDITION

Thank you for selecting the health insurance offered through your university. HealthSmart Benefit Solutions partners with your university to process claims submitted under this plan. ("Claims" are formal requests for the plan to pay for services you've utilized, usually submitted by the providers you see.).

We have received a medical bill from your doctor and need additional information from you in order to complete our processing of your claim. Please provide the information listed below.

1. First name *

Last name: *

2. Your insurance ID# (located on your Insurance ID card) *

3. Group number (located on your Insurance ID card): *

4. Claim # (as shown on your Explanation of Benefits - EOB)

5. Please provide the date of when the symptoms related to the above claim first began (use MM-DD-YYYY format): * 🛈 +

6. During the period specified under the Remarks Code Section on your Explanation of Benefits (EOB) have you consulted any physicians? *

Yes, please proceed to Question 7 and provide details.

No, please type N/A for Question 7.

7. Please provide details regarding the name and address of all physicians consulted during the period specified above. *