Form No. 900508 - Claim Form

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Personal Health Care
1-(800)-553-3164
(540) 342-7352
CLAIM FORM
(Please Print or Type)
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc.
An independent licensee of the Blue Cross and Blue Shield Association.
I. PATIENT AND POLICYHOLDER INFORMATION
Patient Name
I.D. Number
(Last)
(First)
(M.I.)
(Letters if any)
(
)
(Street) (❏ check if new address)
(City)
(State)
(Zip Code)
Patient's Relationship To Policyholder:
Patient's Birthday
Patient's Sex
Mo.
Day
Year
❏ Self
❏ Spouse
❏ Dependent Child
Male
Female
Policyholder Name (as shown on ID card)
Daytime Phone Number
(Last)
(First)
(M.I.)
(in case additional information is needed)
(
)
II. PATIENT'S CONDITION AND TREATMENT
Treatment was for
Condition was due to
If injury, give date
❏ Work-Related Injury/Illness
❏ Auto Accident
❏ Other
❏ Illness
❏ Injury
Mo.
Day
Year
❏ Pregnancy
If work-related, is the patient self-employed and/or eligible for
Worker's Compensation? ❏ Yes
❏ No
First date care was received for this illness or injury
What illness or injury was the patient treated for?
Mo.
Day
Year
III. AUTHORIZATION
I certify that the information I have given is accurate to the best of my knowledge and that I, as the Insured, am claiming benefits
only for the charges incurred by the patient identified above.
I authorize any health care provider of services or supplies, insurance company, or any other organization, institution, or person that
has records or knowledge of me or my health, to furnish to the Medical Review, Claims, and Underwriting departments, or agents
of Anthem Blue Cross and Blue Shield, information concerning services or supplies provided to me or to persons covered, for the
purposes of review, investigation, or evaluation of an application or claim. A copy of this authorization is available to me or my
authorized representative upon request. For claims purposes, this authorization is valid for the duration of coverage.
Policyholder Signature _________________________________________________________________
Date ________________
Please PRINT Policyholder's Name Here: ________________________________________________________________________
IV. INSTRUCTIONS
This claim form is designed to help you, the insured, file itemized health care related bills for you or an enrolled family member.
If your doctor or hospital files directly with Anthem Blue Cross and Blue Shield, please do not file claims for the same services.
Please review your health care bills at least once a month to assure timely filing of claims. (We request that you file claims within
90 days after the covered service is incurred.)
STEP 1.
Complete the Patient and Policyholder Information section.
• Please print or type and complete all sections.
• Make sure to write in your Identification Number as shown on your ID card including any letters in front of
your number.
• Use a separate claim form for each family member and only attach bills for that family member.
STEP 2.
Complete the Patient's Condition (diagnosis) and Treatment section.
INSTRUCTIONS CONTINUED ON OTHER SIDE. SEE BEFORE MAILING
Form No. 900508 (12/02)

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