18. Commercial or Medicare Supplemental Coverage Codes (Check all applicable options.) Dental Drug Durable Medical Equipment (DME) Purchase DME Rental Home Health Inpatient Major Medical Physician Nursing Home Outpatient Vision 19. LTC Coverage Only (Check only one option.) LTC Only Cash LTC Only Reimbursement 20. Coverage Start Date (Required) 21. Open-Ended Coverage? 22. Coverage End Date (Required if Coverage = No) Yes No SECTION III REPORT INFORMATION – 23. Name Individual Completing This Report 24. Date Report Completed – 25. Telephone Number / Extension 26. Name Source of Information Included on This Report 27. Telephone Number / Extension – 28. Comments (Attach a copy of the applicable insurance card.)
18. Commercial or Medicare Supplemental Coverage Codes (Check all applicable options.) Dental Drug Durable Medical Equipment (DME) Purchase DME Rental Home Health Inpatient Major Medical Physician Nursing Home Outpatient Vision 19. LTC Coverage Only (Check only one option.) LTC Only Cash LTC Only Reimbursement 20. Coverage Start Date (Required) 21. Open-Ended Coverage? Yes No 22. Coverage End Date (Required if Coverage = No) SECTION III – REPORT INFORMATION 23. Name – Individual Completing This Report 24. Date Report Completed 25. Telephone Number / Extension 26. Name – Source of Information Included on This Report 27. Telephone Number / Extension 28. Comments (Attach a copy of the applicable insurance card.)