Blue Cross Blue Shield Association Member Claim Form - Free Download | Page 2
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Please indicate where services were rendered if not in North Carolina:
SECTION IV: Services and Supplies To Be Considered For Reimbursement
These may include ambulance services, medical appliances, diabetic supplies, glasses and/or contact lenses or out-of-network services.
BCBSNC requires that procedure codes and diagnosis codes on the itemized receipt be supplied by the provider of
the service.
Claims or itemized receipts received without the information below will be RETURNED.
SECTION V: Private Duty Nursing Enclose a copy of your receipts for these services.
Date of Service
(MM-DD-YY)
Diagnosis Codes or Symptoms You
Sought Treatment For
ChargeProcedure Codes or Description of Service/Supplies
DID YOU REMEMBER TO:
•
Use blue or black ink to complete the form
• Attach the Explanation of Benefits, if applicable
• Attach itemized receipts
•
Provide your signature below
• Keep a copy of this form and your receipts
MAIL THIS FORM, ITEMIZED RECEIPTS AND
EXPLANATION OF BENEFITS (if applicable) TO:
Blue Cross and Blue Shield of North Carolina
P.O. Box 35
Durham, NC 27702
SECTION VI: Mailing Information
Date of Service
(MM-DD-YY)
Indicate
RN, LPN or CNA
Hours
Worked
ChargeName of Nurse License Number
Signature: Date:
Daytime
Phone
Number:
I certify that the information on this form is correct and the expenses incurred were necessary for the services filed.
01-05-07 Office Visit Cold and Flu Symptoms 54.00
EXAMPLE:
03-10-07 Ms. Jane M. Doe LPN 123456 8 160.00
EXAMPLE:
Country: Currency Used:
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