
OTHER IMPORTANT INFORMATION
This section tells about: 
* Form 1490S
* An important message from Medicare 
*Medicare Carriers
* Medicare peer review organizations and quality review
organizations.

              PATIENT'S REQUEST FOR MEDICAL PAYMENT
           IMPORTANT - SEE NEXT PAGE FOR INSTRUCTIONS

Please type or print information                  
Medical insurance benefit Social Security Act
NOTICE: Anyone who misrepresents or falsifies essential
information requested by this form may upon conviction be subject
to fine and imprisonment under Federal Law. No Part B Medicare
benefits may be paid unless this form is received as required by
existing law and regulations (20 CFR 422.510).
SEND COMPLETED FORM TO:
1. Name of Beneficiary from Health Insurance Card 
(Last) (First) (Middle):
2. Claim Number from Health Insurance Card
Patient's Sex (Male) (Female):
3.a. Patient's Mailing Address (City, State, Zip Code)
Check here if this is a new address:
(Street or P.O. Box - Include Apartment Number):
(City) (State) (Zip):
3b. Telephone Number (include Area Code):
4.a. Describe the illness or injury for which Patient Received
Treatment.
4b. Was condition related to:
A. Patient's employment (Yes) (No)
B. Accident (Auto) (Other).
4c. Was patient being treated with chronic dialysis or kidney
transplant? (Yes) (No).
5a. Are you employed and covered under an employee health plan?
(Yes) (No).
5b. Is your spouse employed and are you covered under your
spouse's employee health plan? (Yes) (No).
5c. If you have any medical coverage other than Medicare, such as
private insurance, employment related insurance, State Agency
(Medicaid), or the VA, complete: Name and Address of other
insurance, State Agency (Medicaid), or VA office.
Policyholders Name:
Policy or Medical Assistance No.
NOTE: If you DO NOT want payment information on this claim
released, put an (X) here

I AUTHORIZED ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME
TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION AND HEALTH CARE
FINANCING ADMINISTRATION OR ITS INTERMEDIARIES OR CARRIERS ANY
INFORMATION NEEDED FOR THIS OR A RELATED MEDICARE CLAIM I PERMIT
A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL,
AND REQUEST PAYMENT OF MEDICAL INSURANCE BENEFITS TO ME.

6. Signature of Patient (If patient is unable to sign, see Block
6 on next page)
6b. Date signed.
                            IMPORTANT
 ATTACH ITEMIZED BILLS FROM YOUR DOCTOR(S) OR SUPPLIER(S) TO THE
BACK OF THIS FORM.
FORM HCFA 1490S (SC) (2-87)
Department of Health and Human Services - Health Care Financing
Administration.
               HOW TO FILL OUT THIS MEDICARE FORM

Medicare will pay you directly when you complete this form and
attach an itemized bill from your doctor or supplier.  Your bill
does not have to be paid before you submit this claim for
payment, but you must attach an itemized bill in order for
Medicare to process this claim.
FOLLOW THESE INSTRUCTIONS CAREFULLY:
A.  Completion of this form.
Block 1. Print your name shown on your Medicare Card. (Last Name,
First Name, Middle Name)
Block 2. Print your Health Insurance Claim Number including the
letter at the end exactly as it is shown on your Medicare card.
Check the appropriate box for the patient's sex.
Block 3. Furnish your mailing address and include your telephone
number in Block 3b.
Block 4. Describe the illness or injury for which you received
treatment.  Check the appropriate box in Block 4b and 4c.
Block 5a. Complete this Block if you are age 65 or older and
enrolled in a health insurance plan where you are currently
working.
Block 5c. Complete this Block if you have any medical coverage
other than Medicare.  Be sure to provide the Policy or Medical
Assistance Number.  You may check the box provided if you do not
wish payment information from this claim released to your other
insurer.
Block 6. Be sure to sign your name if you cannot write your
name,make an (X) mark.  Then have a witness sign his or her name
and address in Block 6 too. If you are completing this form for
another Medicare patient you should write (by) and sign your name
and address in Block 6.  You also should show your relationship
to the patient and briefly explain why the patient cannot sign.
Block 6b. Print the date you complete this form.
B. Each itemized bill must show all of the following information:
* Date of each service
* Place of each service
- Doctor's Office
- Outpatient Hospital
- Patient's Home
- Independent Laboratory
- Nursing Home
- Inpatient Hospital
* Description of each surgical or medical service or supply
furnished.
* Change for each service.
* Doctor's or supplier's name and address.  Many times a bill
will show the names of several doctors or suppliers.  It is very
important that the one who treated you be identified.  Simply
circle his/her name on the bill.
* It is helpful if the diagnosis is shown on the physician's
bill.  if not, be sure you have completed Block 4 of this form.
-* Mark out any services on the bill(s) you are attaching for
which you have already filed a claim.
* Attach an Explanation of Medicare Benefits notice from the
other insurer  if you are also requesting Medicare payment.
           COLLECTION AND USE OF MEDICARE INFORMATION
We are authorized by the Health Care Financing Administration to
ask you for information needed in the administration of the
Medicare program.  Authority to collect information is in section
205 (a), 1872 and 1875 of the Social Security Act, as amended.
The information we obtain to complete your Medicare claim is used
to identify you and to determine your eligibility.  It is also
used to decide if the services and supplies you received are
covered by Medicare and to insure that proper payment is made.
The imformation may also be given to other providers of services,
carriers, intermediaries, medical review boards, and other
organizations as necessary to administer the Medicare program.
For example, it may be necessary to disclose information about
the Medicare benefits you have used to a hospital or doctor.
With one exception, which is discussed below, there are no
penalties under social security law for refusing to supply
information.  However, failure to furnish information regarding
the medical services rendered or the amount charged would prevent
payment of the claim.  Failure to furnish any other information,
such as name or claim number, would delay payment of the claim.
It is mandatory that you tell us if you are being treated for a
work related injury so we can determine whether worker's
compensation will pay for the treatment.  Section 1877 (a) (3) of
the Social Security Act provides criminal penalties for
withholding this information.

               AN IMPORTANT MESSAGE FROM MEDICARE

YOUR RIGHTS WHILE YOU ARE a MEDICARE HOSPITAL PATIENT

You have the right to recieve all the hospital care that is
necessary for the proper diagnosis and treatment of your illness
or injury.  According to Federal law, your discharge date must be
determined solely by your medical needs, not by "DRG's" or
Medicare payments.

You have the right to be fully informed about decisions affecting
your Medicare coverage and payment for your hospital stay and for
any post-hospital services.
 
You have the right to request a review by a Peer Review
Organization of any written Notice or Noncoverage that you
receive from the hospital stating that Medicare will no longer
pay for your hospital care.  Peer Review Organizations (PROs) are
groups of doctors who are paid by the Federal Government to
review medical necessity, appropriateness and quality of hospital
treatment furnished to Medicare patients.  The phone number and
address of the PRO for your area is: 

TALK TO YOUR DOCTOR ABOUT YOUR STAY IN THE HOSPITAL
You and your doctor know more about your condition and your
health needs than anyone else.  Decisions about your medical
treatment should be made between you and your doctor.  Ifyou have
any questions about your medical care, don't hesitate to ask your
doctor.  The hospital's patient representative or social worker
will also help you with your questions and concerns about
hospital services.

IF YOU THINK YOU ARE BEING ASKED TO LEAVE THE HOSPITAL TOO SOON
Ask a hospital representative for a written notice or explanation
immediately, if you have not already received one.   This notice
is called a "Notice of Noncoverage."  You must have this Notice
of Noncoverage if you wish to exercise your right to request a
review by the PRO.
The Notice of Noncoverage will state either that your doctor or
the PRO agrees with the hospital's decision that Medicare will no
longer pay for your hospital care.
  If the hospital and your doctor agree, the PRO does not review
your case before a Notice of Noncoverage is issued.  But the PRO
will respond to your request for a review of your Notice of
Noncoverage and seek your opinion.  You cannot be made to pay for
your hosspital care until the PRO makes its decision, if you
request the review by noon of the first work day after you
receive the Notice of Noncoverage.

  If the hospital and your doctor disagree, the hospital may
request the PRO to review your case.  If it does make such a
request, the hospital is required to send you a notice to that
effect.  In this situation the PRO must agree with the hospital
or the hospital cannot issue a Notice of Noncoverage.  You may
request that the PRO reconsider your case after you receive a
Notice of Noncoverage but since the PRO has already reviewed your
case once, you may have to pay for at least one day of hospital
care before the PRO completes this reconsideration.
IF YOU DO NOT REQUEST A REVIEW, THE HOSPITAL MAY BILL YOU FOR ALL
THE COSTS OF YOUR STAY BEGINNING WITH THE THIRD DAY AFTER YOu
RECEIVE THE NOTICE Of NONCOVERAGE.  THE HOSPITAL, HOWEVER, CANNOT
CHARGE YOU FOR CARE UNLESS IT PROVIDES YOU WITH A NOTICE OF
NONCOVERAGE.

      HOW TO REQUEST A REVIEW OF THE NOTICE Of NONCOVERAGE

If the Notice of Noncoverage states that your physician agrees
with the hospital's decision:
You must make your request for review to the PRO by noon of the
first work day after you receive the Notice of Noncoverage by
contacting the PRO by phone or in writing.
The PRO must ask for your views about your case before making its
decision.  The PRO will inform you by phone and in writing of its
decision on the review.
If the PRO agrees with the Notice of Noncoverage, you may be
billed for all costs of your stay beginning at noon of the day
after you receive the PRO's decision.
Thus, you will not be responsible for the cost of hospital care
before you receive the PRO's decision.
If the Notice of Noncoverage states that the PRO agrees with the
hospital's decision:
You should make your request for reconsideration to the PRO
immediately upon receipt of the Notice of Noncoverrage by
contacting the PRO by phone or in writing.

The PRO can take up to three working days from receipt of your
request to complete the review.  The PRO will inform you in
writing of its decision on the review.
Since the PRO has already reviewed your case once, prior to the
issuance of the Notice of Noncoverage, the hospital is permitted
leeway in  billing you for the cost of your stay beginning with
the third calendar day after you receive your Notice of
Noncoverage even if the PRO has not completed its review.
thus, if the PRO continues to agree with the Notice of
Noncoverage, you may have to pay for at least one day of hospital
care.

NOTE:  The process described above is called "immediate review."
If you miss the deadline for this immediate review while you are
in the hospital, you may still request a review of Medicare's
decision to no longer pay for your care at any point during your
hospital stay or after you have left the hospital. The Notice of
Noncoverage will tell you how to request this review.

POST-HOSPITAL CARE
When your doctor determines that you no longer need all the
specialized services provided in a hospital, but you still
require medical care, he or she may discharge you to a skilled
nursing facility or home care.  The discharge planner at the
hospital will help arrange for the services you may need after
your discharge.  Medicare and supplemental insurance policies
have limited coverage for skilled nursing facility care and home
health care.  Therefore, you should find out which services will
or will not be covered and how payment will be made.  Consult
with your doctor, or hospital.  Don't hesitate to ask questions.
ACKNOWLEDGEMENT OF RECEIPT-My signature only acknowledges my
receipt of this Message from (name of hospital) on (date) and
does not waive any of my rights to request a review or make me
liable for any payment.

Signature of beneficiary or person acting on behalf of
beneficiary.



                        MEDICARE CARRIERS

Note: The toll-free or 800 numbers listed below can be used only
in the states where the carriers are located.  Also listed are
the local commercial numbers for the carriers.  Out- of- State
callers must use the commercial numbers.  Many carriers have
installed an automated telephone answering system.  If you have a
touch-tone telephone, you can follow the system instructions to
find out about your latest claims and get other information.  If
you do not have a touch-tone telephone, stay on the line and
someone will help you.

ALABAMA
Medicare/Blue Cross-Blue Shield of Alabama
P.O. Box C-140 Birmingham, Alabama  35283
1-800-292-8855
205-988-2244

ALASKA
Medicare/Aetna Life & Casualty
200 S.W. Market St., P.O. Box 1998
Portland, Oregon 97207-1998
1-800-547-6333
503-222-6831 (customer service site actually in Oregon)

ARIZONA

Medicare/Aetna Life & Casualty
P.O. Box 37200
Phoenix, Arizona 85069
1-800-352-0411
602-861-1968

ARKANSAS

Medicare/Arkansas Blue Cross and Blue Shield
A Mutual Insurance Company
P.O. Box 1418
Little Rock, Arkansas 72203
1-800-482-5525
501-378-2320

CALIFORNIA
Counties of: Los Angeles, Orange, San Diego, Ventura, Imperial,
San Luis Obispo, Santa Barbara
Medicare/Transamerica Occidental Life Insurance Co.
Box 50061
Upland, California  91785-0061
1-800-252-9020
213-748-2311
Rest of State: Medicare Claims Dept.
Blue Shield of California
Chico, California 95976
(In area codes 209, 408,415, 707, 916)
1-800-952-8627
916-743-1583
(In the following area codes--other than Los Angeles, Orange, San
Diego, Ventura, Imperial, San Luis Obispo, and Santa Barbara
counties-- 213, 619, 714, 805, 818)
1-800-848-7713
714-824-0900

COLORADO
Medicare/Blue Shield of Colorado
700 Broadway
Denver, Colorado  80273
1-800-332-6681
303-831-2661

CONNECTICUT
Medicare/The Travelers Ins. Co.
538 Preston Avenue
P.O. Box 9000
Meriden, Connecticut  06454-9000
1-800-982-6819
(In Hartford) 203-728-6783
(In the Meriden area) 203-237-8592

DELAWARE
Medicare/Pennsylvania Blue Shield
P.O. Box 890200
Camp Hill, Pennsylvania  17089-0200
1-800-851-3535

DISTRICT OF COLUMBIA
Medicare/Pennsylvania Blue Shield
P.O. Box 890100
Camp Hill, Pennsylvania 17089-0100
1-800-233-1124

FLORIDA
Medicare/Blue Shield of Florida, Inc.
P.O. Box 2525
Jacksonville, Florida 32231
     For fast service on simple inquiries including requests for
copies of Explanation of Medicare Benefits notices, requests for
Medpard directories, brief claims inquiries (status or
verification of receipt), and address changes: 
1-800-666-7586
For all your other Medicare needs:
1-800-333-7586
904-355-3680

GEORGIA
Medicare/Aetna Life & Casualty
P.O. Box 3018
Savannah, Georgia 31402-3018
1-800-727-0827
912-920-2412

HAWAII
Medicare/Aetna Life & Casualty
P.O. Box 3947
Honolulu, Hawaii  96812
1-800-272-5242
808-524-1240

IDAHO
EQUICOR, Inc.
3150 N. Lakeharbor Lane, Suite 254
P.O. Box 8048
Boise, Idaho  83707
1-800-627-2782
208-342-7763

ILLINOIS
Medicare Claims
Blue Cross & Blue Shield of Illinois
P.O. Box 4422
Marion, Illinois  62959
1-800-642-6930
312-938-8000

INDIANA

Medicare Part B
Associated Ins. Companies, Inc.
P.O. Box 7073
Indianapolis, Indiana 46207
1-800-622-4792
317-842-4151

IOWA
Medicare
IASD Health Services Inc.
(d/b/a Blue Cross & Blue Shield of Iowa)
636 Grand
Des Moines, Iowa 50309
1-800-532-1285
515-245-4785

KANSAS
Counties of:  Johnson, Wyandotte
Medicare/Blue Shield of Kansas City
P.O. Box 169
Kansas City, Missouri 64141
1-800-892-5900
816-561-0900
Rest of State:  Medicare/Blue Shield of Kansas
P.O. Box 239
Topeka, Kansas 66601
1-800-432-3531
913-232-3773

KENTUCKY
Medicare-Part B
Blue Cross & Blue Shield of Kentucky
100 East Vine St.
Lexington, Kentucky 40507
1-800-999-7608
606-233-1441

LOUISIANA
Arkansas Blue Cross & Blue Shield 
Medicare Administration
P.O. Box 95024
Baton Rouge, Louisiana 70895-9024
1-800-462-9666
(In New Orleans) 504-529-1494
(In Baton Rouge) 504-272-1242

MAINE
Medicare/Blue Shield of
Massachusetts/Tri-State
P.O. Box 1010
Biddeford, Maine 04005
1-800-492-0919
207-282-5991

MARYLAND
Counties of:  Montgomery, Prince Georges
Medicare/Pennsylvania Blue Shield
P.O. Box 890100
Camp Hill, Pennsylvania 17089-0100
1-800-233-1124
Rest of State:  Maryland Blue Shield, Inc.
700 E. Joppa Road
Towson, Maryland 21204
1-800-492-4795
301-561-4160

MASSACHUSETTS
Medicare/Blue Shield of Massachusetts, Inc.
1022 Hingham Street
Rockland, Massachusetts 02371
1-800-882-1228
617-956-3994

MICHIGAN
Medicare Part B
Michigan Blue Cross & Blue Shield
P.O. Box 2201
Detroit, Michigan 48231-2201
(In area code 313) 1-800-482-4045
(In area code 517) 1-800-322-0607
(In area code 616) 1-800-442-8020
(In area code 906) 1-800-562-7802
(In Detroit) 313-225-8200

MINNESOTA
Counties of:  Anoka, Dakota, Filmore,
Goodhue, Hennepin, Houston, Olmstead,
Ramsey, Wabasha, Washington, Winona
Medicare/The Travelers Ins. Co.
8120 Penn Avenue South
Bloomington, Minnesota 55431
1-800-352-2762
612-884-7171
Rest of State:  Medicare
Blue Shield of Minnesota
P.O. Box 64357
St. Paul, Minnesota 55164
1-800-392-0343
612-456-5070

MISSISSIPPI
Medicare/The Travelers Ins. Co.
P.O. Box 22545
Jackson, Mississippi 39225-2545
(in Mississippi) 1-800-682-5417
(outside of Mississippi) 1-800-227-2349
601-956-0372

MISSOURI
Counties of:  Andrew, Atchison, Bates,
Benton, Buchanan, Caldwell, Carroll, Cass,
Clay, Clinton, Daviess, DeKalb, Gentry,
Grundy, Harrison, Henry, Holt, Jackson, Johnson, Lafayette,
Livingston, Mercer, Nodaway, Pettis, Platte, Ray, St. Clair,
Saline, Vernon, Worth
Medicare/Blue Shield of Kansas City
P.O. Box 169
Kansas City, Missouri 64141
1-800-892-5900
816-561-0900
Rest of State:  Medicare
General American Life Insurance Co.
P.O. Box 505
St. Louis, Missouri 63166
1-800-392-3070
314-843-8880

MONTANA
Medicare
Blue Shield of Montana, Inc.
2501 Beltview
P.O. Box 4310
Helena, Montana 59604
1-800-332-6146
406-444-8350    

NEBRASKA
The carrier for Nebraska is Blue Shield of Kansas.  Claims,
however, should be sent to:
Medicare Part B
bBlue Cross/Blue Shield of Nebraska 
P.O. Box 3106
Omaha, Nebraska 68103-0106
1-800-633-1113
913-232-3773 (customer service site in Kansas)

NEVADA
Medicare/Aetna Life and Casualty
P.O. Box 37230
Phoenix, Arizona 85069
1-800-528-0311
602-861-1968

NEW HAMPSHIRE
Medicare
Blue Shield of Massachusetts/Tri-State
P.O. Box 1010
Biddeford, Maine 04005
1-800-447-1142
207-282-5991

NEW JERSEY
Medicare/Pennsylvania Blue Shield
P.O. Box 400010
Harrisburg, Pennsylvania 17140-0010
1-800-462-9306

NEW MEXICO
Medicare/Aetna Life and Casualty
P.O. Box 25500
Oklahoma City, Oklahoma 73125-0500
1-800-423-2925
(In Albuquerque) 505-843-7771

NEW YORK
Counties of:  Bronx, Kings, New York, Richmond
Medicare/Empire Blue Cross and Blue Shield
P.O. Box 100
Yorktown Heights, New York 10598
212-490-4444
Counties of:  Columbia, Delaware, Dutchess,
Greene, Nassau, Orange, Putnam, Rockland,
Suffolk, Sullivan, Ulster, Westchester
Medicare/Empire Blue Cross and Blue Shield
P.O. Box 100
Yorktown Heights, New York 10598
1-800-442-8430
b212-490-4444
County of:  Queens
Medicare/Group Health, Inc.
P.O. Box 1608, Ansonia Station
New York, New York 10023
212-721-1770
Rest of State:  Medicare
Blue Shield of Western New York
P.O. Box 5600
Binghamton, New York 13902-0600
607-772-6906
1-800-252-6550

NORTH CAROLINA
EQUICOR, Inc.                 
P.O. Box 671
Nashville, Tennessee 37202
1-800-672-3071
919-665-0348

NORTH DAKOTA
Medicare/Blue Shield of North Dakota
4510 13th Avenue, S.W.
Fargo, North Dakota 58121-0001
1-800-247-2267
701-282-1100

OHIO
Medicare/Nationwide Mutual Ins. Co.
P.O. Box 57
Columbus, Ohio 43216
1-800-282-0530
614-249-7157

OKLAHOMA
Medicare/Aetna Life and Casualty
701 N.W. 63rd St., Suite 100
Oklahoma City, Oklahoma 73116-7693
1-800-522-9079
405-848-7711

OREGON
Medicare/Aetna Life and Casualty
200 S.W. Market St.
P.O. Box 1997
Portland, Oregon 97207-1997
1-800-452-0125
503-222-6831

PENNSYLVANIA
Medicare/Pennsylvania Blue Shield
P.O. Box 890065
Camp Hill, Pennsylvania 17089-0065
1-800-382-1274

RHODE ISLAND
Medicare/Blue Shield of Rhode Island
444 Westminster Mall
Providence, Rhode Island 02901
1-800-662-5170
401-861-2273

SOUTH CAROLINA
Medicare Part B
Blue Cross and Blue Shield of South Carolina
Fontaine Road Business Center
300 Arbor Lake Drive, Suite 1300
Columbia, South Carolina 29223
1-800-868-2522
803-754-0639

SOUTH DAKOTA
Medicare Part B
Blue Shield of North Dakota
4510 13th Avenue, S.W.
Fargo, North Dakota 58121-0001
1-800-437-4762
701-282-1100

TENNESSEE
EQUICOR, Inc.
P.O. Box 1465
Nashville, Tennessee 37202
1-800-342-8900
615-244-5650

TEXAS
Medicare
Blue Cross & Blue Shield of Texas, Inc.
P.O. Box 660031
Dallas, Texas 75266-0031
1-800-442-2620
214-235-3433

UTAH
Medicare/Blue Shield of Utah
P.O. Box 30269
Salt Lake City, Utah 84130-0269
1-800-426-3477
801-481-6196

VERMONT
Medicare
Blue Shield of Massachusetts/Tri-State
P.O. Box 1010
Biddeford, Maine 04005
1-800-447-1142
207-282-5991

VIRGINIA
Counties of:  Arlington, Fairfax;
Cities of:  Alexandria, Falls Church, Fairfax
Medicare/Pennsylvania Blue Shield
P.O. Box 890100, Camp Hill, Pennsylvania 17089-0100
1-800-233-1124
Rest of State:  Medicare/The Travelers Ins. Co.
P.O. Box 26463
Richmond, Virginia 23261
1-800-552-3423
804-254-4130

WASHINGTON
Medicare/Washington Physicians' Service
Mail to your local Medical Service Bureau.
If you do not know which bureau handles your
claim, mail to:
Medicare Washington Physicians' Service
4th and Battery Bldg., 6th Floor
2401 4th Avenue, Seattle, Washington 98121

(In King County) 1-800-422-4087
                 206-464-3711
(In Spokane)     1-800-572-5256
                 509-536-4550
(In Kitsap)      1-800-552-7114
                 206-377-5576
(In Pierce)      206-597-6530
(In Thurston)    206-352-2269
Others:  Collect if out of call area.

WEST VIRGINIA
Medicare/Nationwide Mutual Insurance Co.
P.O. Box 57
Columbus, Ohio 43216
1-800-848-0106
614-249-7157

WISCONSIN
Medicare/WPS
Box 1787
Madison, Wisconsin 53701
1-800-362-7221
(In Madison) 608-221-3330
(In Milwaukee) 414-931-1071

WYOMING
Blue Cross/Blue Shield of Wyoming
P.O. Box 628
102 Indian Hills Shpg. Cntr.
Cheyenne, Wyoming 82003
1-800-442-2371
307-632-9381

AMERICAN SAMOA
Medicare/Hawaii Medical Services Assn.
P.O. Box 860
Honolulu, Hawaii 96808
808-944-2247

GUAM
Medicare/Aetna Life and Casualty
P.O. Box 3947
Honolulu, Hawaii 96812
808-524-1240

NORTHERN MARIANA ISLANDS
Medicare/Aetna Life & Casualty
P.O. Box 3947
Honolulu, Hawaii 96812
808-524-1240

PUERTO RICO
Medicare/Seguros De Servicio De
Salue De Puerto Rico
Call Box 71391 
San Juan, Puerto Rico 00936
1-800-462-7015
809-749-4900

VIRGIN ISLANDS

Medicare/Seguros De Servicio De
Salue De Puerto Rico
Call Box 71391 
San Juan, Puerto Rico 00936
(In St. Croix) 809-778-2665
(In St. Thomas) 809-774-3898MEDICARE PEER REVIEW ORGANIZATIONS (PROs) AND
              QUALITY REVIEW ORGANIZATIONS (QROs)*

ALABAMA*
Alabama Quality Assurance Foundation
Suite 600
600 Beacon Parkway West
Birmingham, AL  35209-3154
205-942-0785

ALASKA
Professional Review Organization for Washington 
(PRO for Alaska)
Suite 300
10700 Meridian Avenue, North
Seattle, WA  98133
206-364-9700

AMERICAN SAMOA/GUAM
Hawaii Medical Services Association
 for American Samoa/Guam
818 Keeaumoku Street
P.O. Box 860
Honolulu, HI  96808
808-944-2173

ARIZONA*
Health Services Advisory Group, Inc
301 East Bethany Home Road
Suite 157, Bldg. B
P.O. Box 16731
Phoenix, AZ  85012
602-264-6382

ARKANSAS
Arkansas Foundation for
 Medical Care, Inc.
P.O. Box 1508
809 Garrison Avenue
Fort Smith, AR  72902
501-785-2471

CALIFORNIA*
California Medical Review Inc.
Suite 500
60 Spear Street
San Francisco, CA  94105
415-882-5800

COLORADO*
Colorado Foundation for Medical Care
1260 South Parker Road 
P.O. Box 1730
Denver, CO  80231-2179                       
303-321-8642

CONNECTICUT*
Connecticut Peer Review Organization, Inc.
100 Roscommon Drive  
Middletown, CT  06457
203-632-2773

DELAWARE
West Virginia Medical Institute, Inc.
(PRO for Delaware)
3412 Chesterfield Ave. S.E.
Charleston, WV 25304
304-925-0461

DISTRICT OF COLUMBIA
Delmarva Foundation for
 Medical Care, Inc.
(PRO for D.C.)
341 B North Aurora Street
Easton, MD  21601
301-822-0697

FLORIDA*
Professional Foundation for
 Health Care, Inc.
Suite 100
2907 Bay to Bay Blvd.
Tampa, FL  33629
813-831-6273

GEORGIA*
Georgia Medical Care Foundation
Suite 1300
4 Executive Park Drive, N.E.
Atlanta, GA  30329
404-982-0411

HAWAII
Hawaii Medical Services Association
818 Keeaumoku Street
P.O. Box 860
Honolulu, HI  96808
808-944-3581

IDAHO
Professional Review Organization for Washington
(PRO for Idaho)
Suite 300
10700 Meridian Avenue, North
Seattle, WA  98133
206-364-9700

ILLINOIS*
Crescent Counties Foundation for Medical Care
350 Shuman Boulevard, Suite 240
Naperville, IL  60540
312-357-8770

INDIANA*
Sentinal Medical Review Organization
2901 Ohio Boulevard
P.O. Box 3713
Terre Haute, IN  47803
812-234-1499

IOWA*
Iowa Foundation for Medical Care
Colony Park, Suite 500
3737 Woodland Avenue
West Des Moines, IA  50265
515-223-2900

KANSAS*
The Kansas Foundation for Medical
 Care, Inc.
2947 S.W. Wanamaker Drive
Topeka, KS  66614
913-273-2552

KENTUCKY*
Sentinal Medical Review Organization
10503 Timberwood Circle, Suite 200
P.O. Box 23540
Louisville, KY  40223
502-339-7442

LOUISIANA
Louisiana Health Care Review
9357 Interline Avenue, Suite 200
Baton Rouge, LA  70809
504-926-6353

MAINE
Health Care Review, Inc.
(PRO for Maine)
Henry C. Hall Building
345 Blackstone Blvd.
Providence, RI  02906
401-331-6661

MARYLAND*
Delmarva Foundation for Medical Care, Inc.
(PRO for Maryland)
341 B North Aurora Street
Easton, MD  21601
301-822-0697

MASSACHUSETTS*
Massachusetts Peer Review Organization, Inc.
300 Bearhill Road
Waltham, MA  02154
617-890-0011

MICHIGAN*
Michigan Peer Review Organization
40500 Ann Arbor Road, Suite 200
Plymouth, MI  48170
313-459-0900

MINNESOTA*
Foundation for Health Care Evaluation
Suite 700
One Appletree Square
Minneapolis, MN  55425
612-854-3306

MISSISSIPPI
Mississippi Foundation for Medical Care, Inc.
P.O. Box 4665
735 Riverside Drive
Jackson, MS  39296-4665

MISSOURI
Quality Quest 
(QRO for Missouri)
One Appletree Square
Suite 700
Minneapolis, MN  55420
612-853-8599

Missouri Patient Care Review Foundation
(PRO for Missouri)
505 Hobbes Lane, Suite 100
Jefferson City, MO  65109
314-893-7900

MONTANA
Montana-Wyoming Foundation for Medical Care
P.O. Box 5117
21 North Main
Helena, MT  59601
406-443-4020

NEBRASKA*
Iowa Foundation for Medical Care 
(PRO for Nebraska)  
Colony Park Building, Suite 500
3737 Woodland Avenue
West Des Moines, IA  50265
515-223-2900

NEVADA*
Utah Peer Review Organization
(PRO/QRO for Nevada)
675 East 2100 South
Salt Lake City, UT  84106-1864
801-487-2290

NEW HAMPSHIRE
New Hampshire Foundation for
 Medical Care
P.O. Box 578
110 Locust Street
Dover, NH 03820
603-749-1641

NEW JERSEY*
The Peer Review Organization of New Jersey, Inc.
Central Division
Brier Hill Court, Building J
East Brunswick, NJ  08816
201-238-5570

NEW MEXICO*
New Mexico Medical Review Association
707 Broadway N.E., Suite 200
P.O. Box 9900
Albuquerque, NM  87119-9900
505-842-6236

NEW YORK
Island Peer Review Organization
9525 Queens Blvd., 10th Floor
Rego Park, NY  11374-4511
718-896-7230

NORTH CAROLINA*
Medical Review of North Carolina
Suite 200
P.O. Box 37309
1011 Schaub Drive
Raleigh, NC  27627
919-851-2955

NORTH DAKOTA
North Dakota Health Care Review, Inc.
Suite 301
900 North Broadway
Minot, ND  58701
701-852-4231

OHIO*
Peer Review Systems, Inc.
Suite 250
3700 Corporate Drive
Columbus, OH  43231-4996
614-895-9900

OKLAHOMA*
Oklahoma Foundation for Peer Review, Inc.
Suite 400 The Paragon Building
5801 Broadway Extension
Oklahoma City, OK  73118
405-840-2891

OREGON*
Oregon Medical Professional Review Organization             
Suite 300
1220 Southwest Morrison
Portland, OR  97205
503-279-0100

PENNSYLVANIA*
Keystone Peer Review Organization, Inc.
777 East Park Drive
P.O. Box 8310
Harrisburg, PA  17105-8310
717-564-8288

PUERTO RICO
Puerto Rico Foundation for Medical Care
Suite 605 Mercantile Plaza
Hato Rey, PR  00918
809-753-6705

RHODE ISLAND*
Health Care Review, Inc.
Henry C. Hall Building
345 Blackstone Boulevard
Providence, RI  02906
401-331-6661

SOUTH CAROLINA
Medical Review of North Carolina
(PRO for South Carolina)
P.O. Box 37309
1011 Schaub Drive, Suite 200
Raleigh, NC  27627
919-851-2955

SOUTH DAKOTA
South Dakota Foundation for Medical Care
1323 South Minnesota Avenue
Sioux Falls, SD  57105
605-336-3505

TENNESSEE
Mid-South Foundation for Medical Care
Suite 400
6401 Poplar Avenue
Memphis, TN  38119
901-682-0381

TEXAS*
Texas Medical Foundation
Barton Oaks Plaza Two, Suite 200
901 Mopac Expressway South
Austin, TX  78746
512-329-6610

UTAH
Utah Peer Review Organization
675 East 2100 South
Suite 270
Salt Lake City, UT  84106
801-487-2290

VERMONT
New Hampshire Foundation for Medical Care
(PRO for Vermont)
P.O. Box 578
110 Locust Street
Dover, NH  03820
603-749-1641

VIRGIN ISLANDS
Virgin Islands Medical Institute
P.O. Box 1556
Christiansted
St. Croix, U.S.A.  VI  00820
809-778-6470

VIRGINIA
Medical Society of Virginia Review Organization
1606 Santa Rosa Road, Suite 235
P.O. Box K 70
Richmond, VA  23288
804-289-5320

WASHINGTON*
Professional Review Organization for
 for Washington
Suite 300
10700 Meridian Avenue, North
Seattle, WA  98133-9075
206-364-9700

WEST VIRGINIA
West Virginia Medical Institute, Inc.
3412 Chesterfield Avenue, S.E.
Charleston, WV  25304                             
304-925-0461

WISCONSIN*
Wisconsin Peer Review Organization
2001 W. Beltline Highway
Madison, WI  53713
608-274-1940

WYOMING
Montana-Wyoming Foundation for Medical Care
P.O. Box 5117
21 North Main
Helena, MT  59601
406-443-4020

*Designates States where the PRO is also the QRO