Form C-14764 - International Claim Form - Blue Shield Of California (Page 2 of 2) in pdf

General Information

Blue Shield of California/Blue Shield of California Life & Health Insurance Company’s International Claim Form is to be used to

submit institutional and professional claims for benefits for covered medical services received outside the United States, Puerto Rico and the

U.S. Virgin Islands. For filing instructions for other claim types (e.g., dental, prescription drugs, etc.), contact Blue Shield of California or

Blue Shield of California Life & Health Insurance Company.

The International Claim Form must be completed for each patient in full, and accompanied by fully itemized bills. It is not necessary for you

to convert currency.

Since any documents you submit cannot be returned, please be sure to keep photocopies of all bills and supporting documentation for your

personal records.

International Claim Form Instructions

Please complete all items on the claim form. If the information requested does not apply to the patient, indicate N/A (Not Applicable). Special

care should be taken when completing the following items:

2. Other Health Insurance

If the patient has other health insurance coverage, please complete items A through K as completely as possible. It is especially important to

indicate the name and address of the other insurance company and the policy or identification number of that coverage, as well as the name

and birth date of the person who holds that policy.

In addition, if the patient has received benefits from any other health insurance plan, the Explanation of Benefits Form furnished by the other

insurance company pertaining to these charges must be included with the claim.

A clear photocopy of the other insurance company’s Explanation of Benefits Form is acceptable in place of the original document.

4. Charges

Please list here the bills that are being claimed. Although the original itemized bills must be submitted, your listing will enable us to process

the claim more quickly and accurately. If additional space is needed, please use a separate sheet of paper to list the following information.

4A. Name and Address of provider – As indicated on the bill. Multiple bills from the same provider may be included on the same line, as

long as they are for the same type of service.

4B. Type of provider – For example: hospital, nurse, physician, clinic, physical therapist, etc.

4C. Description of service or supply – For example: hospital admission, office x-ray, laboratory test, surgery, etc.

4D. Date of service or purchase – Inclusive dates may be indicated for bills containing multiple dates of service

(i.e., 1/10/04 – 1/20/04).

4E. Charges: Indicate the total charge for each applicable service or supply.

5. Signature

The International Claim Form must be signed and dated by the subscriber, spouse, domestic partner or the patient. Attach the original

itemized bills showing a separate charge for each service. If the bill has already been paid, please indicate.

Itemized Bill Information

Each provider’s original itemized bill must be attached and must contain:

• The letterhead indicating the name and address of the person or organization providing the service

• The full name of the patient receiving the service

• The date of each service

• A description of each service or supply

• The charge for each service or supply

This completed claim form, together with itemized bills and supporting documentation, should be submitted to:

Blue Shield of California/Blue Shield of California Life & Health Insurance Company

International Claims

P.O. Box 272550

Chico, CA 95927-2550 USA

C-14764 (7/05)

Form C-14764 - International Claim Form - Blue Shield Of California Page 2

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