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Center for Advanced Legal Studies *

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3163

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Health Science

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Oct 30, 2023

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Member Name : Member ID: Issuer ID: Note to Provider: Ask this member for the card from their Medicaid health plan. Providers should use that card for billing help. No health plan card? Pharmacists can use the non-managed care billing information on the back of this card. Front of Card Members: Keep this card with you. This is your medical ID card. Show this card to your doctor when you get services. To learn more, go to www.YourTexasBenefits.com or call 800-252-8263. Miembros: Lleve esta tarjeta con usted. Muestre esta tarjeta a su doctor al recibir servicios. Para más información, vaya a www.YourTexasBenefits.com o llame al 800-252-8263. THIS CARD DOESN'T GUARANTEE ELIGIBILITY OR PAYMENT FOR SERVICES. Providers: To verify eligibility, call 800-925-9126. Non-managed care pharmacy claims assistance: 800-435-4165 Non-managed care Rx billing: RxBIN: 610084 / RxPCN: MEDICAID / RxGRP: DRTXPROD Back of Card My Information Medical Plan Dental Plan Pharmacy Benefits Main Doctor Member ID: Name: Date of Birth: Gender: Program Name: Medicare Coverage: Plan Name: Plan Phone: Plan Name: Plan Phone: RxBIN: RxPCN: RxGRP: Name: Address: Phone: Call this number if you have questions about your doctor or health services. Call this number if you have questions about your dentist or dental services. This document does not guarantee eligibility or payment for services. To learn more, call 800-252-8263. Medicare Beneficiary Identifier: Your Texas Benefits JACKSON ANTHO LOPEZ STEGMAN 751719243 610258 11/30/2021 Date Card Sent: 751719243 JACKSON ANTHO LOPEZ STEGMAN 09/29/2021 M STAR COMMUNITY FIRST HEALTH 8004342347 DENTAQUEST 8005160165 610602 MCD CFG N
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