Qualification Form

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Qualification Form

For More information and or concerns
Please email us at :

information@cmmadvisorscorp.com

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Email *

First Name *

Last Name *

Address *

Are You a Union Member Retired or Current ? *

NYSUT

CSEA

Other:

Required

Do You Currently Have A Catastrophic Major Medical Policy NYSUT CMM Plan Document *

(Policy # E-160,672) NEW YORK CIVIL SERVICE RETIRED EMPLOYEES ASSOCIATION (CSREA) - CATASTROPHIC MAJOR MEDICAL CERTIFICATE (E-160,672)

(Policy # E-170,129) for benefit period effective dates before January 1, 2014.

(Policy # CMMI-001) for benefit period effective dates between January 1, 2014 & December 31, 2017.

( Policy # CMMI-003) for benefit period effective dates on or after January 1, 2018

Other:

Required

Do you currently have major & secondary medical Insurance ? Select all that applies *

Medicare

United Health

BlueCross

Option 4

AARP

GHI

Other:

Required

Have you had a Catastrophic Major Medical event
Hospital in patient or Hospital out patient ?
*

Yes

Required

Date of Catastrophic Major Medical event

YYYY

Do you have out of pocket spending for
*

RX Prescriptions

Dr copays

other treatments

Required

Do you want our help in receiving reimbursements…if yes check yes and submit to qualify
*

Yes

Required

Submit

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