Form 1081.000-901 - Claim Form To Pay Insured/subscriber 2001
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1
2P.O. Box 660044
Claim Form
Dallas, Texas 75266-0044
to Pay
Insured/Subscriber
Each item on this form needs to be completed.
Please Print or Type
Instructions for completion are listed on the reverse side.
Insured/Subscriber Name (Last, First, Middle Initial)
1
2
Group Number
Insured/Subscriber Identification Number (from ID card)
Mailing Address
Patient's Full Name (Last, First, Middle)
City & State
Zip Code
Patient's Sex
Patient's Date of Birth
Month
Day
Year
_____ /_______ /____
Male
Female
Insured Employed?
Date of Retirement
Patient's Relationship to Insured
Month
Date
Year
Yes
No
Retired
1.
Self 2.
Spouse 3.
Child 4.
Other (explain)
____________________
/
/
Type of treatment received:
3
Month
Day
Year
Check only one type and attach itemized statements.
Injury — Date of Accident:
______ /______ /______
Please use a separate claim form for each different type
Illness — Date of First Symptom:
______ /______ /______
of treatment.
Pregnancy — Date of Conception:
*Please note: Preventive care includes immunizations,
______ /______ /______
routine well baby care, routine physical examinations,
Preventive — Date of Service:
______ /______ /______
vision and hearing exams.
Describe: Diagnosis, Symptoms of Illness or Injury or explain Preventive or Routine care received.
4
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Was Illness or Injury work connected?
Yes
No
Name and Address of Employer
5
__________________________________________________
6
If Injury, was motor vehicle involved?
Yes
No
__________________________________________________
7
Is patient covered under any other Health Benefits Plan (besides Medicaid, Medicare or CHAMPUS)?
Yes
No
Insuring Co.____________________________________
Policy # ______________________
Month
Day
Year
Address_______________________________________
Effective Date of Coverage
______/______/______
Employer______________________________________
Sex
Male
Female
Birthdate
______/______/______
(Insured)
(Insured)
Insured________________________________________
Relationship to Patient_________________________________
If the other coverage is primary, attach the other insurance company's Explanation of Benefits
8
Medicare — Is the Patient:
Month
Day
Year
a) Entitled to Benefits Under Medicare Hospital Insurance (Part A)?
Yes
No Effective ______/______/______
b) Entitled to Benefits Under Medicare Medical Insurance (Part B)?
Yes
No Effective ______/______/______
c) Entitled to Benefits Under Medicare due to a disability?
Yes
No Effective ______/______/______
Patient's Medicare Identification No. (From Medicare ID Card)____________________________
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I certify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named
above. Authorization is hereby given to any Hospital, Physician, Dentist, Provider, Insurance Carrier or other entity to give
Blue Cross and Blue Shield of Texas, upon request, any medical information which the Plans in their judgment deem
necessary to the adjudication of this claim. Any person who knowingly presents a false or fraudulent claim for the payment
of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
_____________________________________
_________________
__________________________
Signature of Insured
Date
Daytime Telephone Number
Itemized Bill(s) for Covered Services and Supplies must be attached
(See Instructions on Reverse Side)
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
1081.000-901
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