Appendix C - Sample CAMA coupon

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Appendix C

SAMPLE CAMAChronic and Acute Medical Assistance COUPON

RECIPIENTAn individual who is receiving a public assistance program. IDENTIFICATION CARD		STATE OF ALASKA			MEDICAL ASSISTANCE PROGRAM
NAME OF ELIGIBLE PERSON(S)		CLIENT I.D. NO.	ELIG. MONTH	DOB	SUBTYPE	E.C.	RESOURCES	MEDICARE
DOE	JOHN	0600000586	1102	0461	GJ	21	**	********
*************	*************	**********		****	**	**	**	********
*************	*************	**********		****	**	**	**	********
*************	*************	**********		****	**	**	**	********

** AUTHORIZATION STATEMENT **

AUTHORIZATION LIMITED TO PHYSICIAN SERVICES, PRIOR-AUTHORIZED OUTPATIENT HOSPITAL RADIATION AND CHEMOTHERAPY, 3 PRESCRIPTIONS PER MONTH, AND LIMITED MEDICAL SUPPLIES.

HEALTH CARE PROVIDERAny doctor or health facility which has agreed to provide medical services to recipients under the medical assistance program. INSTRUCTIONS: THIS CARD IDENTIFIES THE PERSON LISTED ABOVE AS A CAMAChronic and Acute Medical Assistance RECIPIENTAn individual who is receiving a public assistance program. WHO IS ELIGIBLE TO RECEIVE MEDICAL ASSISTANCE FROM HEALTH CARE PROVIDERS ENROLLED TO USE THE ALASKA MEDICAL PAYMENT SYSTEM. PROVIDERS MUST VERIFY THAT THE BEARER OF THIS CARD IS THE NAMED PERSON AND WRITE THE CLIENT I.D. NUMBER ON OR ATTACH THE IDENTIFICATION CARD TO EACH CLAIM.

NOTE: Cooperation with third party resources includes supplying your providerAny doctor or health facility which has agreed to provide medical services to recipients under the medical assistance program. with medical insurance coverage information such as detailed information. Providers must accept payment from all resources prior to billing CAMAChronic and Acute Medical Assistance.

83 00007572 N0000035

DOE JOHN

111 LONG AND WINDING ROAD

ANCHORAGE, AK 99501

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