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Microsoft word - medical insurance record booklet.doc
A useful tool for tracking important information
about your medical insurance and medications
Name of Beneficiary: ____________________________________________ Medicare Part B Claim Number: ___________________________________ Address of Medicare Carrier: _____________________________________
Company Phone Number: ____________________________________
Group Policy Number: ________________________________________
Company Phone Number: ____________________________________
1. Request itemized bills from all providers. 2. Number all paperwork relating to same services with the same Item Number you enter in
column A. It will make record filing and management easier.
3. When you receive a bill, fill in columns B through E: Date of Service (not date of bill),
Provider (name of Doctor or Hospital), Total Charge and Date Claim Filed with Medicare/Medicaid (ask doctor’s office if they sent it for you).
4. When you receive your Medicare/Medicaid Explanation of Benefits (EOB) form, fill in
columns F through H: Amount Approved (by Medicare/ Medicaid), Amount Paid by Medicare/Medicaid and Is Bill Assigned? (yes or no - this will be indicated on the top of Medicare/Medicaid Explanation of Benefits form).
5. If you have other additional health insurance, fill in columns I and J: Date Claim Filed and
Amount Paid after the claim was processed.
Determine the Balance Due (how much you owe the provider) and enter in column K. If the provider accepts assignment, the amount not approved by Medicare/ Medicaid should not be paid to the provider. To determine what you owe:
If the bill is assigned, the amount approved by Medicare/Medicaid (column F) minus
the amount paid by Medicare/Medicaid (column G), minus the amount paid by other insurance companies (column J) equals the amount you owe.
If the bill is not assigned, the total charge (column D), minus the amount paid by
Medicare/Medicaid (column G), minus the amount paid by other insurance companies (column J) equals the amount you owe.
6. In column L, enter the Date Paid / Check Number (check you used to pay the provider)
7. In column M, enter any Notes or information you feel may be helpful. Use the inside back
If you have questions regarding Medicare/Medicaid,
please contact your local Social Security office.
Use this worksheet to keep track of your personal medical information. My Personal Information Date of Birth
Other Physicians Information Name of Physician
• Use this worksheet to keep track of all your medications, including prescription drugs, over-
the-counter drugs, herbal supplements, and vitamins.
• Share the information with your doctors and pharmacists at all visits. • Keep a printed copy always with you. You should review and update this record whenever you: • Start or stop a new medicine. • Change a dose. • Visit your doctor
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FPL provides a special toll-free number (1-800-432-6554) that allows hearing or speech-disabled customers to use a teletype communication system to communicate with FPL’s customer service personnel.
Serious financial problems can strike any family or individual due to the loss of a job, illness, etc. When a customer is having financial difficulty, FPL’s ASSIST program will help the customer reach the social service
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FPL’s Medically Essential Service Program is for customers whose electric service is medically essential, as certified by a physician licensed in the State of Florida. Electric service may be medically essential if the customer has continuously operating electric-powered medical equipment necessary to sustain life, or avoid serious medical complications requiring immediate hospitalization. This program does not guarantee uninterrupted service or exempt a customer from paying the electric bill. Customers requesting participation in this program may call FPL to request an application and physicians’ certification form.
Florida Power & Light Company serves about half of Florida’s people, a population with many different lifestyles and many different needs.
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Booklet produced and provided by FPL Special Consumer Services
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