Medicare Supplemental COB Declaration Form
Member Information
Full Name
Date of Birth
Medicare ID
Phone Number
Address
Other Insurance Information
Do you have any other health insurance?
Yes
No
If yes, Insurance Company Name
Policy or Group Number
Effective Date
Coordination of Benefits
Which insurance is your primary coverage?
Medicare
Other Insurance
Comments
Certification
I certify that the above information is true and correct to the best of my knowledge.
Signature
Date