Submit this form to the Eligibility Department to verify that the patient is eligible for services. If you select a patient first, most of the fields will fill in automatically.

Patient Last Name
Last name of the patient whose eligibility is being verified.

Patient First Name
First name of the patient whose eligibility is being verified.

Patient Date of Birth
Date of birth of the patient. This field will be used to determine if the patient is a Senior.

Address
Address of the patient

Subscriber Last Name
The last name of the subscriber, if it is not the same as the patient name above. If the patient and subscriber are the same, either leave this field blank or type ?same?. The system will default the patient name into the field upon submission

Subscriber First Name
First name of the subscriber, if it is not the same as the patient name above.

Health Plan
Select the appropriate Health Plan from the drop down list.

Eligibility Problem Type
Select a problem type for the request from the drop down list:

Verify member BTMG Eligibility
New born
Verify member BTMG PCP assignment
COB (please specify issue in Notes)
Other (please specify issue in Notes)

Health Plan ID
The member number of the subscriber.

Subscriber SSN
The Social Security Number of the subscriber

Notes
Free text field provided for any additional information necessary to complete the request.