Other health insurance coverage questionnaire

Let us know if you have health insurance from another health plan.


Medicare requires us to verify if members have additional health insurance. This information helps us process your claims correctly. We ask for this information from you even if you only have coverage through us.

* denotes a required field

Numbers and dashes only.

Is Sharp Health Plan your only health insurance coverage?*

Other health insurance information

Type of coverage
Type of policy
* denotes a required field

Please sign below.

Read the disclosure below, and type your full name to certify that the information in this form is accurate.

By completing and submitting this form, you certify that all information provided in this form is complete and accurate to the best of your knowledge, and you authorize Sharp Health Plan to verify the information provided in this form.

* denotes a required field

Sharp Direct Advantage is offered by Sharp Health Plan. Sharp Health Plan is an HMO with a Medicare contract. Enrollment with Sharp Health Plan depends on contract renewal. Read the full disclaimer.

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