Member Health Expense Report
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2Member Health Expense Report
Blue Cross Blue Shield of Georgia (BCBSGA)
P.O. Box 105370
Atlanta, GA 30348-5370
Please see instructions for filing on page two.
Member no.
Group no.
No. of items attached
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SeCtion 1: PAtient inFoRMAtion — Person who received services
Last name
First name
M.I.
Sex
Relationship to member
Date of birth
Male
Female
Self
Spouse
Child
Other ___________________
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SeCtion 2: PRiMARY MeMBeR inFoRMAtion
Last name
First name
M.I.
Address
City
State
ZIP code
IMPORTANT: Check here if this is a new address
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SeCtion 3: otHeR CoVeRAGe inFoRMAtion
Is this patient covered by any other group health care plan or Medicare? ..............
Yes
No
Was condition related to an automobile accident? ......................................................
Yes
No
Was condition related to employment? ..........................................................................
Yes
No
If “Yes” to either of these questions, please complete the following:
Policyholder’s name
Policy no.
Date of birth
Insurance company’s name
Please indicate type of coverage
Health
Dental
Vision
Pharmacy
Insurance company’s address
City
State
ZIP code
Employer’s name
Group no.
Medicare no.
Medicare
Medicare effective date
Part A
Part B
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SeCtion 4: MeDiCAL inFoRMAtion
Is this an
Date of injury
Illness
Injury If injury, date of injury is required.
Describe the illness or injury which required treatment
How did the injury occur?
ReAD tHiS: Any intentional false statement in this application or willful misrepresentation relative thereto is a violation of the law.
I authorize the release of any medical information necessary to process this claim and also certify that the above information is correct.
Patient or authorized person signature
Date
X
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Note: Please indicate the physician providing service on each bill. For questions, please call the number on the back of your ID card.
Blue Cross and Blue Shield of Georgia, Inc., is an independent licensee of the Blue Cross and Blue Shield Association.
25617GAMENBGA 11/11
The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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379530 25617GAMENBGA WGS Member Health Expense Prt FR 11 11
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