Other health insurance coverage questionnaire

Medicare requires us to verify if members have additional health insurance. This information helps us process your claims correctly. We ask for this information from you even if you only have coverage through us.

* denotes a required field

Read the disclosure below, and type your full name to certify that the information in this form is accurate.

By completing and submitting this form, you certify that all information provided in this form is complete and accurate to the best of your knowledge, and you authorize Sharp Health Plan to verify the information provided in this form.