Section II. I understand that the information requested is to assist NCSBT in accurately coordinating benefits with Medicare and in meeting its mandatory reporting obligations under Medicare law. Printed name of Injured Party Printed name of parent or guardian, if Injured Party is a minor Signature of Injured Party (if a minor, signature of parent or guardian) Date *NOTE: In Attachment B, the words “you” and “your” refer to the Injured Party. Printed name of Injured Party Printed name of parent or guardian, if Injured Party is a minor For the reason(s) listed below, I have not provided the information requested. I understand that if the Injured Party is a Medicare beneficiary and I do not provide the requested information, myself and/or the Injured Party may be violating my/our obligations to assist Medicare in coordinating benefits to pay claims correctly and promptly.
Appears in 2 contracts
Sources: No Fault Medical Expense Coverage, No Fault Medical Expense Coverage