COB for Out-of-Network Services Claim
Patient Information
Patient Name
Date of Birth
Member ID
Address
Primary Insurance Details
Insurance Company
Policy Number
Group Number
Policyholder Name
Relationship to Patient
Secondary Insurance Details
Insurance Company
Policy Number
Group Number
Policyholder Name
Relationship to Patient
Service Information
Date(s) of Service
Provider Name
Provider NPI/ID
Out-of-Network Reason
Claim Details
Total Billed Amount
Amount Paid by Primary
Amount Paid by Patient
Attach Explanation of Benefits (EOB)
Signature
Name
Date