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Coverage Questionnaire Form

After you enroll, if you have more than one medical plan, you can complete the Coordination of Benefits/Other Coverage form. Having more than one medical plan may save on medical costs by coordinating your benefits. The information you provide will help us determine if your other medical plan is primary or secondary to your KelseyCare Advantage plan.

Q1. At the present time are you (the member) or your spouse working?*

Q2. Do you or your spouse have group health plan coverage through an employer?*

Q3. Do you have group health plan coverage through a family member other than your spouse?*

Acknowledgement *

Always at Your Service

Call Member Services at 713-442-CARE (2273)
or toll-free at 1-866-535-8343 (TTY: 711)

8 a.m.– 8 p.m. | 7 days a week | From October 1 to March 31

8 a.m.– 8 p.m. | Monday – Friday | From April 1 to September 30

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