Customer Service

Other Insurance Information

This Other Insurance Information form is used when we need to coordinate benefits with other health plans that may cover customers and their qualified dependents.

Arise Health Plan Customer Information

First Name of party insured by Arise Health Plan:

Last Name of party insured by Arise Health Plan:

Phone number of party insured by Arise Health Plan:

Email Address of party insured by Arise Health Plan:

Customer ID from Arise Customer ID Card:

Other Insurance Information

First Name of party insured by other insurance:

Last Name of party insured by other insurance:

Group number from other insurance ID card:

ID number from other insurance ID card:

Names of dependents listed on other insurance plan (enter 'none' if no dependents are covered):

Name of other insurance plan:

Address of other insurance plan:

City, State & Zip Code of other insurance plan:

Effective date of other insurance plan (dd/mm/yyyy):