Subscriber Claim Form For Services Received Outside California
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1University of California
Subscriber Claim Form for Services Received Outside California
This form is used to submit claims when you have paid out-of-pocket for covered services you have received outside
of California.
Please send this completed form to: Blue Shield of California, P.O. Box 1505, Red Bluff, CA 96080 or by fax (888) 842-6294.
If you have any questions about this form, call the Customer Service number on your Blue Shield member ID card.
Important instructions for subscriber-submitted claims
• Use a separate form for:
Please include a copy of your bill/claim that includes
– Each member of your family
all of the following information:
– Each different provider of service
• Date of service
– Each itemized bill
• Charges for each individual procedure
• Diagnosis code(s)
• Please print or type.
• Fill in all items completely.
• Procedure code(s)
• S ign your name in the space provided.
• Place of treatment
Not following these instructions may result in your claim
• Provider name
being delayed or returned to you.
• Provider tax ID
Subscriber name
Alpha prefix Subscriber ID number
Group number
(Last name, First, MI)
1
Mail address – Street
City
State ZIP
Is address new?
c Yes
c No
Name of patient
Date of birth Month
Day
Year
(Last name, First, MI)
/
/
Patient’s gender c Male
c Female
Relationship to subscriber c Self
c Spouse/domestic partner
c Child
Describe briefly patient’s illness or injury, and if injury, how it occurred
2
Patient was treated for
Date of injury, onset
Month
Day
Year
c Injury
c Illness
of illness, or pregnancy
/
/
c Pregnancy
If yes, coverage effective date
Month
Day
Year
Is patient retired? c Yes
c No
/
/
If yes, policy identification number
Does patient have other health coverage? c Yes
c No
Name of insuring company
Effective date
3
Address of insuring company
Type of plan
c Group
c Individual
Name of policyholder
Sex
Date of birth Name of employer
If yes, patient’s date of birth
Was condition related to employment? c Yes
c No
Part A effective
Part B effective
Does patient have Medicare? c Yes
c No
4
Subscriber’s signature
I certify that the foregoing information is accurate and complete, and authorize the release of any medical
information necessary to process this claim.
X ____________________________________________________________________________________________ Date ____________________
Please send this completed form to: Blue Shield of California, P.O. Box 1505, Red Bluff, CA 96080 or by fax (888) 842-6294.
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