Florida Banner

Coordination of Benefits

NOTE: (Items marked with an " * " are required fields)

*Florida Medicaid Member First Name
*Florida Medicaid Member Last Name
*Florida Medicaid ID Number
Name of other insurance company
Other insurance address/phone
Name of family member insured thru them
Relationship of family member to Florida Medicaid member
Effective date of other coverage
Group, Policy, Member Numbers of other coverage
Type of other coverage

Please only click Submit once