Download Blue Cross Blue Shield International Medical Claim Form for Free

1. Patient Information — 1A. Alpha prefix Identification number Copy this from your Blue Cross Blue Shield identification card.

1B. Patient’s name (First, middle initial, last) 1C. Patient’s date of birth 1D. Patient’s sex

MM/DD/YYYY Male Female

1E. Name of subscriber (First, middle initial, last) 1F. Subscriber’s date of birth 1G. Patient’s relationship

to subscriber

MM/DD/YYYY

Self

Spouse Child

1H. Subscriber’s current mailing address (Street, city, state, and country or ZIP code) 1I. Patient’s e-mail address

2. Other Health Insurance — Is the patient covered under other health insurance, including Medicare A or B Yes No

If yes, complete 2A through 2K below.

2A. Name and address of other insuring company

2B. Type of policy 2C. Effective date 2D. Termination date 2E. Policy or identification number

Family Individual MM/DD/YYYY MM/DD/YYYY of other coverage

2F. Type of coverage Hospital: Yes No 2G. Name of subscriber 2H. Date of birth

Medical: Yes No Mental illness: Yes No MM/DD/YYYY

2I. Employer of subscriber 2J. Employment status

Active employee Retired employee

2

K.

If patient is covered under Medicare, complete the following: Medicare Part A:

Yes

No

Medicare Part B:

Yes

No

Effective date ________________ Effective date _________________

3. Diagnosis — 3A. Describe illness, injury, or symptoms requiring treatment and onset date of symptoms or injury.

3B. Was patient’s treatment due to a work-related accident or condition Yes No

3C. Complete for care related to accidental injuries

Date of accident _____________________________________ Location: At home Auto Other ____________________________

Time of accident ____________________________________ If the accident was caused by someone else, attach a statement describing the accident.

4. Charges — Use a separate line to list each type of service or provider and attach itemized bills for all services.

4A. Name and address of 4B. Type of provider 4C. Description of service 4D. Dates of service 4E. Charges

provider making charge

or purchase

.................................................................................................................................... .............................................................................. ............................................................................................................................... .......................................................................... .................................................

5. Payee — Select one of the following payment options:

5A. Make payment to subscriber; provider has been paid.

1. Currency – Please check your preference for payment: Currency on itemized bill(s) U.S. dollars

2. Payment Method – Please select your preference for how to receive your payment: Check (Provide current telephone number) _____________________________

Bank Wire. If you want to receive a bank wire provide the following:

Subscriber name as it appears on bank account: _____________________________________________________ Bank name: _____________________________________________

Bank’s Physical Address: _____________________________________________________________________________________________________________________________________

Account # /IBAN: ________________________________________________________________________Routing # / ABA / BIC / SWIFT: _______________________________________

5B. Make payment to provider (hospital, doctor), if appropriate. Please complete and sign to authorize direct payment to provider.

I, the undersigned, authorize and request payment for benefits due herein to be made to the following provider of services, if such direct payment is deemed appropriate

by Blue Cross and Blue Shield:

Name of provider _______________________________________ Signature of subscriber or spouse ________________________________________________ Date _________________

6. Signature — I certify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named above. Authorization is

hereby given to any provider of service, that participated in any way in the patient's care, to release to the subscriber's Blue Cross and Blue Shield Plan and its business

associates in any country any medical or other personal information that they deem necessary to provide service or adjudicate this claim, recognizing that applicable

law concerning personal information may differ among countries. Authorization is also given to the subscriber's Blue Cross and Blue Shield Plan and its business

associates in any country to collect, use or release any medical or other personal information that they deem necessary to provide service, adjudicate a claim or as

otherwise described in such Blue Cross and Blue Shield Plan’s Notice of Privacy Practices.

Signature of subscriber or patient _________________________________________________________________________________________________ Date _________________________

BlueCard Worldwide

®

International Claim Form

Please see the instructions on the reverse side of this form before completing. Please type or print.

Blue Cross and Blue Shield Plans are

independent licensees of the Blue

Cross and Blue Shield Association.

/ /

Send completed form to: BlueCard Worldwide Service Center or claims@bluecardworldwide.com

P.O. Box 261630

Miami, FL 33126 USA

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