STATE OF MARYLAND WEIGHT LOSS MEMBERSHIP REIMBURSEMENT FORM

1.Subscribers Legal Name (Last, First, Middle Initial) Patients Legal Name (Last, First, Middle Initial)

Membership Number Patients Sex

q Male q Female

Patients Relationship to Subscriber q Self q Spouse

Subscribers Address (Street) q Check box if NEW address Patients Date of Birth

Month Day Year

City State Zip Code

Telephone Number

Group Number

2. IMPORTANT: ALL INFORMATION MUST BE PROVIDEDReimbursement eligible for Employee, Spouse and Retirees only: The State of Maryland will reimburse Weight Loss Program membership fee and/or monthly fees not to exceed $150 per benefit period. Details confirming the membership fee and monthly fee on company letterhead and a paid receipt must accompany this claim form.

Name of Weight Loss Program Address of Weight Loss Program

Telephone of Weight Loss Program Requested Membership Fee

3. I certify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named above.Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Authorization is hereby given to any hospital, physician, or other provider which participated in any way in my care and treatment to release to CareFirst BlueCross BlueShield any medical information which they in their judgement deem necessary to the adjudication of this claim.

SIGNATURE OF SUBSCRIBER DATE

4.Please submit this completed form, along with your receipt and membership information, to:

Mail Administrator

P.O. Box 14115Lexington, KY 40512-4115

HAVE YOU ATTACHED YOUR ITEMIZED RECEIPT?

Administrative Use OnlyDo not write in this space

Provider# Initials

CST2588-1S (11/14)

CareFirst BlueCross BlueShield is the business name of CareFirst of Maryland, Inc. and is an independent licensee of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.

Registered trademark of CareFirst of Maryland, Inc.

Notice of Nondiscrimination and Availability of Language Assistance Services

CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. CareFirst:

Provides free aid and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

If you need these services, please call 855-258-6518. If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator. Civil Rights Coordinator, Corporate Office of Civil Rights Telephone Number 410-528-7820

Mailing Address P.O. Box 8894 Baltimore, Maryland 21224

Fax Number 410-505-2011

Email Address civilrightscoordinator@carefirst.com You can file a grievance by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

mailto:civilrightscoordinator@carefirst.comhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://www.hhs.gov/ocr/office/file/index.html

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.

Registered trademark of CareFirst of Maryland, Inc.

Foreign Language Assistance Attention (English): This notice contains information about your insurance coverage. It may contain key dates

and you may need to take action by certain deadlines. You have the right to get this information and assistance in

your language at no cost. Members should call the phone number on the back of their member identification card.

All others may call 855-258-6518 and wait through the dialogue until prompted to push 0. When an agent

answers, state the language you need and you will be connected to an interpreter.

(Amharic) -

855-258-6518 0

d Yorb (Yoruba) ttlko: kys y n wfn npa i adjtf r. le n wn dt pt o s le n lti

gb gbs n wn j gbdke kan. O ni t lti gba wfn y ti rnlw n d r lf. wn m-gb

gbd pe nmb fn t w lyn kd dnim wn. wn mrn le pe 855-258-6518 k o s dr npas jrr

tt a fi s fn lti t 0. Ngbt aoj kan b dhn, s d t o f a s so p m gbuf kan.

Ting Vit (Vietnamese) Ch : Thng bo ny cha thng tin v phm vi bo him ca qu v. Thng bo c th

cha nhng ngy quan trng v qu v cn hnh ng trc mt s thi hn nht nh. Qu v c quyn nhn

c thng tin ny v h tr bng ngn ng ca qu v hon ton min ph. Cc thnh vin nn gi s in thoi

mt sau ca th nhn dng. Tt c nhng ngi khc c th gi s 855-258-6518 v ch ht cuc i thoi cho

n khi c nhc nhn phm 0. Khi mt tng i vin tr li, hy nu r ngn ng qu v cn v qu v s c

kt ni vi mt thng dch vin.

Tagalog (Tagalog) Atensyon: Ang abisong ito ay naglalaman ng impormasyon tungkol sa nasasaklawan ng iyong

insurance. Maaari itong maglaman ng mga pinakamahalagang petsa at maaaring kailangan mong gumawa ng

aksyon ayon sa ilang deadline. May karapatan ka na makuha ang impormasyong ito at tulong sa iyong sariling

wika nang walang gastos. Dapat tawagan ng mga Miyembro ang numero ng telepono na nasa likuran ng kanilang

identification card. Ang lahat ng iba ay maaaring tumawag sa 855-258-6518 at maghintay hanggang sa dulo ng

diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot ang ahente, sabihin ang wika na kailangan mo

at ikokonekta ka sa isang interpreter.

Espaol (Spanish) Atencin: Este aviso contiene informacin sobre su cobertura de seguro. Es posible que

incluya fechas clave y que usted tenga que realizar alguna accin antes de ciertas fechas lmite. Usted tiene

derecho a obtener esta informacin y asistencia en su idioma sin ningn costo. Los asegurados deben llamar al

nmero de telfono que se encuentra al reverso de su tarjeta de identificacin. Todos los dems pueden llamar al

855-258-6518 y esperar la grabacin hasta que se les indique que deben presionar 0. Cuando un agente de seguros

responda, indique el idioma que necesita y se le comunicar con un intrprete.

(Russian) !

. ,

.

. ,

.

855-258-6518 , 0.

, .

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.

Registered trademark of CareFirst of Maryland, Inc.

(Hindi) : - 855-258-6518 0 ,

s-w (Bassa) To uu Cao! B nia k a ny e ke m gbo kpa o ni fu a-fa-tiin ny je dyi. B nia k

ee we j e m ke wa m m ke nyu nyu hw we ea ke zi. m ni kpe m ke b nia k ke gbo-

kpa-kpa m m dye e ni ii-wuu mu m ke se wii o p. Kpoo ny e m a fn-na nia e waa

I.D. kaa ein ny. Ny t sein m a na nia k: 855-258-6518, ke m m fo tee wa ke m gbo c m ke

na ma 0 k dyi paain hw. ju ke ny o dyi m g juin, po wuu m m po dyi, ke ny