Breast Pump Claim Form Complete all of the information below. Attach receipt showing exact model purchased to this form. Member ID Number: ___ ___ ___ — ___ ___ —___ ___ ___ ___ — ___ ___ Member Birth Date: ___________________________________ Member Name: ____________________________________________________________________________________________________ (Please print) First Middle Last Address: __________________________________________________ City:____________________ State: ______ Zip: _______________ Expected Delivery Date: _______________ CHOOSE ONE (RMHP will cover ONE option) Purchase – Breast Pump Manual (E0602) Purchase – Breast Pump Electric (E0603NU) Provide name, address and telephone number of supplier/retailer where Breast Pump was purchased: ___________________________________ Name Date of Purchase: ____________________
_______________________ Telephone Number
Provider TIN: _____________________________
I certify the information on this claim form is true and correct to the best of my knowledge. I authorize the release of any medical information necessary to process this claim. Signature: ______________________________________________________________ Date: _______________________________ Member (or Parent if a Minor) Reimbursement will be made to the Member for eligible expenses according to provisions of the Member’s Evidence of Coverage. Reimbursement is limited to commercial individual and group plan members only. There is no reimbursement for CHP+, Medicaid, or Medicare Members. If you need help to obtain additional forms, please call Rocky Mountain Health Plans Customer Service: 970-243-7050 or 800-346-4643. If you are hearing impaired and use TTY equipment, call 711 for Relay Colorado.
For Internal Use Only: Researched by __________________
Return Completed Form to: Rocky Mountain Health Plans Attn: Claims 2775 Crossroads Blvd. P.O. Box 10600 Grand Junction, CO 81502-5600
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Form CM 50 MK614R06/19/12