Claim Form
This form does not need to be completed if your services were provided by a contracting hospital,
CLEAR DATA
physician, or dentist. These contracting providers will file a claim on your behalf.
Patient Name
Date of Birth
Last
First
MI
MM/DD/YYYY
Identification No.
Group No.
Home Address
Street
City
State
ZIP Code + 4
Home Phone No.
Cell Phone No.
Area Code
Area Code
Work Phone No.
Fax No.
Area Code
Area Code
E-mail Address
Change of Address: If the address above is a different address, please check this box.
Alternate Payee Information: Please complete this section if someone other than the cardholder is to be reimbursed.
Alt. Payee Name
Last
First
MI
Alt. Payee Address
Street
City
State
ZIP Code + 4
Alt. Home Phone No.
Alt. Cell Phone No.
Area Code
Area Code
Alt. Work Phone No.
Alt. Fax No.
Area Code
Area Code
Alt. E-mail Address
Is this service related to an accident?
Yes
No
If yes, complete the following:
Date of Accident
How did the accident occur?
Where did the accident occur?
Home
School
Work
Other
Was this injury/illness the result of occupational circumstances for which Workmen’s Compensation is liable?
Yes
No
Has a Workmen’s Compensation claim been filed?
Yes
No
If no, why not?
Was the injury the result of physical contact with a motor vehicle?
Yes
No
If yes, complete the following:
Type of motor vehicle involved
If this was a motorcycle accident, do you have No Fault Motor Vehicle Insurance?
Yes
No
Your auto insurance has a maximum dollar limitation on benefits payable for medical expenses. Please contact your auto insurance
company and provide the following:
• Personal injury protection maximum dollar amount
• Excess medical benefits maximum dollar amount
• Complete itemized statement indicating provider of service, date of service and to whom paid.
Please continue on other side.→
34-4 02/12
An Independent Licensee of the Blue Cross and Blue Shield Association.