Anthem Subscriber Submitted Claim Form

P.O. Box 17849

Denver, CO 80217-0849

ONE PATIENT AND ONE PROVIDER PER CLAIM FORM

Subscriber Submitted Claim

SEE REVERSE SIDE FOR CLAIM FILING INSTRUCTIONS

3. PATIENT NAME (Last, First, Initial) (PLEASE PRINT)

1. NUMBER

2. GROUP NUMBER

4. PATIENT BIRTHDATE

MO.

DAY

YR.

5. PATIENT SEX

6. PATIENT RELATIONSHIP TO SUBSCRIBER

7. SUBSCRIBER NAME (Last, First, Initial)

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MALE

FEMALE

SELF

SPOUSE

CHILD

OTHER

8. SUBSCRIBER ADDRESS (Street, City, State, Zip Code)

COORDINATION OF BENEFITS INFORMATION – ANSWER “YES” OR “NO” TO ALL QUESTIONS

IF NO GO TO QUESTION 10

9a. NAME AND ADDRESS OF EMPLOYER

9b. NAME AND ADDRESS OF COMPENSATION CARRIER 9c. DATE OF ACCIDENT

9. WERE THESE SERVICES REQUIRED AS A

RESULT OF A JOB-RELATED ILLNESS OR

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ACCIDENT?

YES

NO

IF NO GO TO QUESTION 11

10a. DATE OF ACCIDENT OR INJURY

10. WERE SERVICES REQUIRED FOR A CONDITION RESULTING

FROM AN ACCIDENT OR INJURY CAUSED BY

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ANOTHER PARTY?

YES

NO

IF NO GO TO QUESTION 12

11a. NAME OF POLICYHOLDER

11b. NAME AND ADDRESS OF INSURANCE COMPANY

11c. POLICY NUMBER

11. IS PATIENT COVERED BY ANY OTHER

GROUP HEALTH BENEFIT PLAN?

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YES

NO

IF NO GO TO QUESTION 13

12a. NAME AND ADDRESS OF AUTOMOBILE INSURANCE COMPANY

12b. DATE OF ACCIDENT

12. WERE SERVICES REQUIRED DUE TO

AN AUTOMOBILE ACCIDENT?

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YES

NO

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IF NO GO TO QUESTION 14

PART A

YES

NO

13a. MEDICARE NUMBER

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13. IS PATIENT ELIGIBLE FOR PART A AND/OR

PART B

YES

NO

OR MEDICARE?

14. ILLNESS OR SYMPTOMS — FOR REIMBURSEMENT

15. NAME OF PROVIDER OR HOSPITAL FACILITY OF SERVICE

16. IF PLACE OF SERVICE WAS OUTPATIENT HOSPITAL, PROVIDE NAME OF

HOSPITAL FACILITY

78. IF WE HAVE QUESTIONS, WHO MAY WE CONTACT?

Name: _______________________________________

Phone No. __________________________

PLEASE COMPLETE THE FOLLOWING AS A SUMMARY OF THE ITEMIZED BILLS YOU HAVE ATTACHED TO THIS CLAIM FORM

19. DATE OF

20. PLACE OF

21. CHARGE FOR

22.

*

SERVICE

SERVICE

SERVICE

BRIEFLY DESCRIBE THE SERVICE(S) YOU RECEIVED

*

23. TOTAL CHARGES FOR

PLACE OF SERVICE

WHICH YOU ARE REQUESTING

0—OFFICE

OP—OUTPATIENT HOSPITAL

IP—INPATIENT HOSPITAL

L—LAB

$

CONSIDERATION OF PAYMENT

___________________

H—HOME

NH—NURSING HOME

P—PHARMACY

24. I CERTIFY TO THE ACCURACY AND COMPLETENESS OF ALL INFORMATION REPORTED BY ME ON THIS FORM AND AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY

TO PROCESS THIS CLAIM.

SIGNATURE

DATE

FULL SIGNATURE AND DATE

REQUIRED ON EACH FORM

INCOMPLETE FORMS MAY DELAY PROCESSING. PLEASE ENSURE ALL FIELDS ARE ANSWERED.

8216O (REV. 03-04)

An independent licensee of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. ® Registered marks Blue Cross and Blue Shield Association.

WHITE/Anthem Blue Cross and Blue Shield — CANARY/Subscriber