Coordination of benefits (FL Medicaid)

Florida Medicaid coordination of benefits

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

Florida Medicaid member first name

Florida Medicaid member last name

Florida Medicaid ID number

Name of other insurance company

Other insurance address/phone

Name of family member insured through them

Relationship of family member to Florida Medicaid member

Effective date of other coverage

Group, policy, and member numbers of other coverage

Type of other coverage

Last Date of Update 12/21/2021