Coordination of benefits (Florida Healthy Kids)

Florida Healthy Kids coordination of benefits

Note: (Items marked with an * are required fields)

* Member first name

* Member last name

FL Healthy Kids ID

Name of other insurance company

Name of family member insured through them

Relationship of family member to FL Healthy Kids member

Effective date of other coverage

Group, policy, and member numbers of other coverage

Type of other coverage

Comments