UNISYS

/
Request for Health Care Benefits
/ Unisys Medical Plan – PPO Options One and Two;
Unisys Post-Retirement and Extended Disability Medical Plan (PRM)

Instructions

/ 1. A new Request for Health Care Benefits form must be completed every time you request benefits. You can use this form or the Benefits Request Transmittal on the back of your previous explanation of benefits statement from the Unisys Benefits Payment Office. Submit a separate form for each family member.
2. Answer all questions completely. Leaving answers blank will
delay your request.
3. Attach itemized billings, or ask your health care provider
to complete the applicable section on page 2 of this form.
An itemized bill must show:
(a) the patient’s name,
(b) date of birth,
(c) relationship to you,
(d) the date of service or purchase,
(e) the condition being treated,
(f) the service provider’s name, and
(g) the amount charged for each service or supply. / 4. If another plan (including Medicare) is responsible to pay before the Unisys plan, attach a copy of the other plan’s payment explanation worksheet.
5. You are encouraged to accumulate small expenses and
submit them on a monthly or quarterly basis.
6. Mail the Request for Health Care Benefits to:
Unisys Benefits Payment Office – Medical Plan
c/o Aetna, Inc.
PO Box 981107
El Paso TX 79998-1107
7. If you have any questions, call toll-free:
1-800-223-3580
Outside the U.S., call (952) 594-6250
Print the Information Below:

Employee

/ Employee name (first, mi, last) / Employee Social Security number
Information / - / -
Street address / City / State / ZIP code
Assignment
Option / Assignment of Benefits: Sign here only if you wish to authorize payment directly to the physician or supplier.
Sign here Date

Patient

/ Patient name (first, mi, last) / Patient date of birth (mm/dd/year) / Sex
Information / / / Male / Female
Patient’s relationship to employee / Is the condition related to patient’s job?
Self / Spouse / Child / Domestic partner / Yes / No
If child, is child married? / Is the condition related to an accident?
Yes / No / Yes / No
If child and age 19 or over, is child a full-time student? / If yes, accident date / Where?
Yes / No / /
If yes, name and location (city and state) of school / Description of accident (Attach additional statement if necessary)

Other

/ Is spouse employed? / If yes, name of spouse / Do you or your dependents have other group health coverage?
Information / Yes / No / Yes / No
Spouse’s Social Security number / Spouse’s date of birth (mm/dd/year) / If yes name of other coverage
- - / /
Spouse’s employer / Telephone number of other health care administrator
Employee
Signature / I certify that, to my knowledge, this form does not contain any false, misleading or incomplete information. I also authorize the release of all records or other information which may be necessary to determine benefits payable to me.
Sign here / Date
Physician or Supplier Statement
14. Date of illness (first symptom) or injury (accident )
or pregnancy (lmp) / 15. Date first consulted you
for the condition / 16. Has patient ever had same or similar symptoms?
Yes / No
17. Date patient able to return to work / 18. Dates of disability / Dates of partial disability
From / Through / From / Through
19. Name of referring physician / 20. For services related to hospitalization,
give hospitalization dates
Admitted / Discharged
21. Name and address of facility where services rendered (if other than home or office) / 22. Was laboratory work performed
outside your office? / If Yes, what were
the charges?
Yes / No
23. Diagnosis or nature of injury / (Relate diagnosis to procedure in column D below by reference to number 1, 2, 3, etc. or DX code)
1.
2.
3.
24. / A / B* / C. Fully describe procedures, medical services or supplies
furnished for each date given: / D† / E / F / G
Date of
service / Place of
service / Procedure code
(CPT) /
(Explain unusual services or circumstances) / T.O.S. / Charges / Days or units / Diagnosis code
(ICD-9-CM)
25. Signature of physician or supplier
Signed Date / 26. Enter the taxpayer identification number
to be used for 1099 reporting purposes.
You are required by the authority of law to
furnish your taxpayer identification number. / 27. Total charge
. / 28. Amount paid
. / 29. Balance due
.
31. Physician’s or supplier’s name, address, ZIP code, and telephone number
30. Your patient’s account number
32. Provider’s degree or license
*Place of Service codes
1
2
3
4
5 / - (IH)
- (OH)
- (O)
- (H)
/ - Inpatient Hospital
- Outpatient Hospital
- Doctor’s Office
- Patient’s Home
- Day Care Facility (PSV) / 6
7
8
9
0 /
- (NH)
- (SNF)
- (OL) / - Night Care Facility (PSV)
- Nursing Home
- Skilled Nursing Facility
- Ambulance
- Other Locations / A
B
C
D / - (IL)
- (RTC)
- (STF) / - Independent Laboratory
- Other Medical Surgical Facility
- Residential Treatment Center
- Specialized Treatment Facility
†Type of Service codes
1
2
3
4
5
/ - Medical Care
- Surgery
- Consultation
- Diagnostic X-ray
- Diagnostic Laboratory
/ 6
7
8
9
0
/ - Radiation Therapy
- Anesthesia
- Assistance at Surgery
- Other Medical Service
- Blood or Packed Red Cells
/ A
M
Y
Z / - Used DME
- Alternative Payment for Maintenance Dialysis
- Second Opinion on Elective Surgery
- Third Opinion on Elective Surgery
This form is available as a Word template via
dotcom - Forms/Ordering - Corporate Forms. / 1 of 2 / 4305 3545-005 (3/03)
This form is available as a Word template via
dotcom - Forms/Ordering - Corporate Forms. / 1 of 2 / 4305 3545-005 (3/03)