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* Is the insurance company Blue Cross/Blue Shield?
How many CU members are/were covered by this policy? [enter value] ______________
What type of insurance plan is it?
For definitions Information Booklet »
Is this fee for service plan a -
Is this special purpose insurance plan -
* Specify: [enter text] ___________
Was the policy obtained on an individual or group basis?
Are the policy premiums paid -
Are any premiums paid through payroll deductions?
What is your part of the regular health insurance payment including all payroll deductions? [enter value] ______________
What period of time is covered by the regular payment?
* Specify: [enter text] ___________
Since the first of the reference month, were any payments made on this policy?
How many payments were made? [enter value] ______________
What was the total expense paid for this policy since start of the reference month? [enter value] ______________
How much was paid this month? [enter value] ______________
Did you have any other hospitalization or health insurance plans?
Go to Section 15 Part A - Medical and Health Expenditures - Screening Questions for Payments »
Go to CAPI Home Page »
Last Modified Date: November 21, 2006