Blue Cross Blue Shield Association Medical Claim Form 2 - Free Download
This form is provided by Blue Cross and Blue Shield of Illinois.
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Are there any OTHER medical benefits available to you, your spouse, or your dependents from OTHER Group Insurance, including OTHER Blue Cross and Blue Shield policies,
OTHER Employer, Labor or Professional Organizations, School, etc.
Yes (provide below) No
POLICY HOLDER NAME: SOCIAL SECURITY NUMBER (optional):
___ ___ ___/ ___ ___/ ___ ___ ___ ___
POLICY HOLDER IS:
Member Spouse Child OTHER, please explain relationship:
INSURANCE CARRIER NAME: POLICY NUMBER: EFFECTIVE DATE:
ADDRESS: PHONE NUMBER:
(__ __ __)__ __ __-__ __ __ __
ID NUMBER -- Copy this from your Blue Cross and Blue Shield Identification Card.
NOTICE TO ALL PARTIES COMPLETING THIS FORM: It is fraudulent to fill out this form with information
you know to be false or to omit important facts. Criminal and/or civil penalties can result from such acts.
HEALTH INSURANCE CLAIM FORM
Send Completed Claim Form To:
Blue Cross and Blue Shield of Illinois
P.O. Box 805107
CHICAGO, IL 60680-4112
PLEASE PRINT OR TYPE CLEARLY
GROUP NUMBER
: IDENTIFICATION NUMBER:
PATIENT INFORMATION -- A separate claim form must be completed for each family member.
PATIENT’S FULL LEGAL NAME (Last, First, Middle Initial) SEX: SOCIAL SECURITY NUMBER (optional): DATE OF BIRTH
Male Month Day Year
Female
___ ___ ___/ ___ ___/ ___ ___ ___ ___
PATIENT IS:
Member Spouse Child OTHER, please explain relationship:
PAYEE:
MAKE PAYMENT TO THE PROVIDER (hospital, doctor etc.), OR
MAKE PAYMENT TO MEMBER, the provider has been paid
MEMBER INFORMATION
MEMBER (POLICY HOLDER) NAME: (As shown on your Blue Cross and Blue Shield SOCIAL SECURITY NUMBER (optional): DATE OF BIRTH
ID Card) Month Day Year
___ ___ ___/ ___ ___/ ___ ___ ___ ___
CURRENT ADDRESS: HOME PHONE:
(__ __ __)__ __ __-__ __ __ __
IF COVERAGE IS THRU GROUP (EMPLOYER) NAME: WORK PHONE:
YOUR EMPLOYER, PROVIDE
(__ __ __)__ __ __-__ __ __ __
CLAIM INFORMATION
IS CLAIM FOR AN ACCIDENTAL INJURY IS THIS A WORKERS COMPENSATION CLAIM DATE OF ACCIDENT:
Yes No Yes No
BRIEFLY DESCRIBE INJURY:
COMPLETE BELOW IF NON-ACCIDENTAL INJURY OR ILLNESS
DATE FIRST TREATED
: BRIEFLY DESCRIBE THE CONDITION(S) FOR WHICH THE PATIENT RECEIVED THESE SERVICES:
(You can usually copy the diagnosis or description of service from the provider bill.)
RELEASE OF INFORMATION: I certify that the above information is correct and that the bills attached were incurred by the patient
listed above. I understand that Blue Cross and Blue Shield’s use or disclosure of individually identifiable health information, whether
furnished by me or obtained from other sources such as medical providers, shall be in accordance with the federal privacy
regulations under HIPAA (Health Insurance Portability and Accountability Act of 1996).
Sign
Her
e _____________________________________________________________________________________________ Date__________________________
Signature of Member
OTHER INSURANCE INFORMATION
3
20479.0607
IF CLAIM IS FOR CHILD 19 OR OLDER—IS CHILD
: A full-time student Yes No Handicapped Yes No
