Request For Payment Form
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1REQUEST FOR PAYMENT
Please complete the following information and submit with receipt/claim.
Only one form is needed per patient each time you submit a claim.
SUBSCRIBER NAME ___________________________________________________
IF ACCIDENT OR MEDICAL EMERGENCY
SUBSCRIBER ADDRESS _________________________________________________
DATE OF ONSET/ACCIDENT _____________________________________
____________________________________________________________________
WORK RELATED
NO
YES
____________________________________________________________________
TYPE OF ACCIDENT ___________________________________________
Check if New Address
GROUP NUMBER _____________________________________________________
WAS A THIRD PARTY INVOLVED?
NO
YES
IDENTIFICATION NUMBER ______________________________________________
For prescription drugs include on each receipt Rx Number and Name of Drug, Date
Rx Filled, and indicate “NEW” or “REFILL.”
PATIENT’S NAME _____________________________________________________
I CERTIFY THAT THE INFORMATION THIS CLAIM FORM IS CORRECT AND COMPLETE.
PATIENT’S BIRTDATE
____________________________________________
SUBSCRIBER SIGNATURE _______________________________________________
PATIENT’S SEX
M
F
DATE
____________________________________________________________
PATIENT’S RELATIONSHIP TO
SELF
SPOUSE
CHILD
SUBSCRIBER
DOES THE PATIENT HAVE OTHER COVERAGE?
NO
YES
Please mail form and receipts to:
DOES THE PATIENT HAVE MEDICARE COVERAGE?
NO
YES
HIGHMARK BLUE CROSS BLUE SHIELD WEST VIRGINIA
If yes, submit Medicare Explanation of Benefits with claim.
ATTENTION: CLAIMS DEPARTMENT
PO BOX 7026
EFFECTIVE DATES
PART A ________________ PART B _________________
WHEELING, WV 26003-0766
DIAGNOSIS/NATURE OF ILLNESS _________________________________________
____________________________________________________________________
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Parent category: Business