Health Benefits Claim Form
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1
2Employee’s
FOR OFFICE USE ONLY
Name _____________________________________
1
Identification
Number ____________________________________
HEALTH BENEFITS
(Please include the letters if included on your ID Card)
CLAIM FORM
Patient’s
2
Name _____________________________________
First
Middle Initial
Last
The Patient is:
Female
Male
3
And Is The:
Employee
Employee’s Spouse Employee’s Child
Piedmont Service Center
Patient’s
Month
Day
Year
4
Post Office Box 6000
Date of
Greenville, SC 29606-6000
Birth
__ __
__ __
__ __
Employee’s
Check If New Address
5
Mailing
Address _______________________________________________________________________________________
Street
City
State
ZIP Code
Was any treatment required as a result of accidental injury?
Yes
No
Date of accident ____________________
6
7
If an accident, was another person at fault?
Yes
No
If yes, please explain. _____________________________
Was any injury or illness work related?
Yes
No
Is the patient covered by Medicare Health Insurance, Part A?
Yes
No
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Or by Supplemental Medical Insurance, Part B?
Yes
No
If yes, please attach your “Explanation of Medicare Benefits.” It is necessary to process your claim.
Complete the following Medicare Health Insurance Benefit Number # __________________________________________
Is the patient covered under any other health benefit plan?
Yes
No
If yes, please attach your “Explanation of Benefits” from the other Insurance Company. Also, please complete this entire
section as it is necessary to process this claim.
A. Policyholder’s Name _____________________________________________________________________________
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Relationship of Policyholder to Patient ________________________________________________________________
B. Name of other Policyholder’s Employer _______________________________________________________________
Address of other Policyholder’s Employer ______________________________________________________________
City
State
ZIP Code
C. Name of other Insurance Company __________________________________________________________________
Address of other Insurance Company ________________________________________________________________
CERTIFICATION OF MEMBER
I certify that the above information is correct and that the foregoing expenses were incurred for the above named patient. I request el-
igible benefits for these expenses. I authorize any physician, nurse, hospital or other provider or supplier in possession of records or
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information concerning the patient to furnish such information to Blue Cross and Blue Shield of South Carolina upon request.
(Be sure to complete items 1-9 on this form and attach itemized statements for all expenses. Absence of this information may cause
a delay in processing this claim.)
Date __________________ Employee’s Signature _______________________________________________________
11778 (11/00)
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