Claims Reimbursement Form - MESSA.org · Claims Reimbursement Form Please complete this entire form...
Transcript of Claims Reimbursement Form - MESSA.org · Claims Reimbursement Form Please complete this entire form...
1475 Kendale Blvd., P.O. Box 2560East Lansing, Michigan 48826-2560
517.332.2581 800.292.4910Fax: 517-333-6229
www.messa.org
Claims Reimbursement FormPlease complete this entire form and attach/include as much information as possible.
Important Note: Your bill/receipt must accompany this form for processing. Please remember to attach your itemized bill/receipt for reimbursement consideration.
MESSA Member / Patient Information
Claim Information
Provider Information
Reimbursement Instructions
(Please Print)First Name of Member
First Name of Patient
Address
Address 2
City State Zip Code Work / School Phone #
School District
Home Phone #
Last Name of Patient Patient’s Date of Birth (MM/DD/YY)
Last Name of Member Enrollee ID Number
( )
( )
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Type of Service:
Diagnosis:
Individual Charge Detail for Each Type of Service:
Diagnosis Code Number:
Procedure Code:(i.e., lab, office visit, supply, x-ray)
Name of Provider or Facility
Address
Address 2
City Zip CodeState
National Provider Identification (NPI) Number
Telephone Number
Tax ID Number
Degree
Send payment to: Member Provider
MES - MSRev. 2/24/14Pr. 2/14 - 1PDF