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
FPL Budget Billing® allows customers to receive relatively consistent monthly electric bills throughout the year. By paying for less electricity than is actually used during months of peak electric usage, and more than the actual usage in other months, customers can budget their electric costs as they budget for other fixed expenses, such as insurance, rent or car payments. FPL 62Plus® recognizes the unique financial circumstances of customers on fixed incomes, such as seniors and retirees. This program provides qualified customers up to 30 days to pay their electric bill, regardless of when they receive their monthly pension or Social Security checks. FPL Friendly Reminder® reduces the risk of unnecessary disconnection of the electric service of customers who may forget to pay their bill, or who may be unable to pay on time because they are ill or traveling. Another person, such as a “caregiver,” family member or neighbor, is designated to receive a copy of any Final Notice issued by FPL, protecting the customer from possible discontinuation of service because their bill inadvertently went unpaid. To make FPL bill payment more convenient and efficient, FPL offers several free alternatives to regular mail. With FPL Automatic Bill Pay® and FPL E-Mail Bill® with CheckFree, bill payments are made automatically by a direct debit to the customer’s bank account. Both programs help customers save time and postage costs, do not require checks, and prevent late payments due to illness or busy schedules. Through FPL’s web site - www.fpl.com - customers can use FPL Pay Online, and FPL also offers Pay By Phone. These two services are simple, immediate and free.
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
organization that can offer the kind of assistance needed. The FPL Care to Share Program , which is funded by customer, employee and corporate contributions, is designed to assist qualified customers who are in a crisis situation and unable to pay their electric bill.
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.
FPL works with its customers through Special Consumer Services like Health and Safety Programs, Billing and Payment Programs, Special Communications Services and Crisis Assistance - all designed to enhance the lives of our customers and build a better community for all of us. For more information, please visit our website at www.fpl.com
Booklet produced and provided by FPL Special Consumer Services
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