State Health Plan Comprehensive Benefits Claim Form
ADVERTISEMENT
1
2STATE HEALTH PLAN COMPREHENSIVE BENEFITS CLAIM FORM
South Carolina State Budget and Control Board, Office of Insurance Services
To file a claim, complete and sign this form. You must attach copies of itemized bills,
including diagnoses, to receive proper payment for your claim.
1
Insured’s Name
I.D.#/SSN ZCS
Patient’s Name
2
First
Middle Initial
Last
The patient is:
Female
Male
3
The patient is the:
Insured
Insured’s Spouse
Insured’s Child
Patient’s Date of Birth
4
Month
Day
Year
Insured’s
Mailing Address
5
Street
City
State
ZIP Code
6
Was the treatment required as a result of accidental injury?
Yes
No
If yes, give date of accident
MEDICARE INFORMATION
Is the patient covered by Medicare?
Yes
No
If yes, give date of Medicare No.
If yes, does the patient have Medicare Part A (Hospital Benefits)?
Yes
No
Date coverage became effective _____/ ____/ ____
7
If yes, does the patient have Medicare Part B (Medical Surgical Benefits)?
Yes
No
Date coverage became effective ____/ ____/ ____
Is patient actively working?
Yes
No
Is the patient disabled?
Yes
No
Is the patient retired?
Yes
No
If yes, give the date of retirement
____/ ____/ ____
OTHER GROUP INSURANCE COVERAGE
Is the patient covered under any other health benefit plan?
Yes
No
If yes, you must complete this section so your claims can be processed.
A.
Name of other insurance company
8
Address of other insurance company
B.
Name of insured under this policy (policyholder)
Relationship to patient
Insured’s date of birth
C.
Effective date of other insurance policy
Policy number of other insurance policy
Always attach your Explanation of Benefits or explanation of payment from your other plan.
CERTIFICATION OF MEMBER
I certify that the above information is correct and that the foregoing expenses were incurred for the above-named patient. I
9
authorize any physician, nurse, hospital or other provider or supplier in possession of records or information concerning
the patient to furnish such information to Blue Cross and Blue Shield of South Carolina upon request.
INSURED’S SIGNATURE
DATE
Please see the other side of this form for mailing instructions.
(11318) Rev. 1/95
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business