Medical Claim Form
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Transcript of Medical Claim Form
An
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blueshieldca.com
Subscriber’s Statement of Claim
Send this claim to: Blue Shield of California, P.O. Box 272540, Chico, CA, 95927-2540.
This form is to be used only when the provider of service does not submit your claim directly to Blue Shield.
Check with the Provider to be sure no claim has been submitted.
Duplicate claims will not only be rejected but may delay payment of the original claim.
Important instructions• Useaseparateformfor: A.Eachmemberofthefamily B.Eachdifferentproviderofservice C.Eachitemizedbill
• Printortype
• Fillinallitemscompletely• Signyournameinthespaceprovided
Failure to comply with these instructions may result in your claim being delayed or returned to you.
Exceptions:• PrimaryMedicarecoverage A.SubmitclaimtoMedicarefirst. B.Completeboxes1and4only. C.AttachyourexplanationofMedicarebenefitsformandacopy
ofitemizedservicestothisclaimandsendalltoBlueShield.
• Foreignclaims AnyservicesrenderedoutsideoftheUnitedStatesoritsterritories
mustincludetheUScurrencyexchangerateorvalueandthetranslationforallbilledservices.
1Subscribername(Last,First,MI) Subscribernumber Groupnumber
Mailaddress City State ZIP Isaddressnew?c Yesc No
2Patient’sname Dateofbirth(mo/day/yr) Gender
c Malec Female
Relationshiptosubscriberc Selfc Spousec Child
Describebrieflypatient’sillnessorinjuryand,ifinjury,howitoccured
Patientwastreatedforc Injuryc Illnessc Pregnancy
Dateofinjury,onsetofillnessorpregnancy Ispatientretired?c Yesc No
IfYes,effectivedate
3Doespatienthaveotherhealthcoverage?c Yesc No
IfYes,policyIDnumber Nameofinsuringcompany Effectivedate
Addressofinsuringcompany Typeofplanc Groupc Individual
Nameofpolicyholder Genderc Malec Female
Dateofbirth(mo/day/yr)
Nameofemployer
4Wasconditionrelatedtoemployment?c Yesc No
DoespatienthaveMedicare?c Yesc No
IfYes,dateofbirth(mo/day/yr)
PartAeffectivedate PartBeffectivedate
Subscriber’s signatureIcertifythattheforegoinginformationisaccurateandcomplete,andauthorizethereleaseofanymedicalinformationnecessarytoprocessthisclaim.
X________________________________________________________________________________________Date_______________