Form Cl-438 - Medical Expense Claim - Bluecross Blueshield Of Alabama
ADVERTISEMENT
1
2MEDICAL EXPENSE CLAIM
®
®
FILL OUT A SEPARATE FORM FOR EACH PATIENT.
An Independent Licensee of the Blue Cross and Blue Shield Association.
Use this form to file a claim for any eligible medical expenses when your physician or other provider does not file a claim.
Please print clearly with black ink (or type).
1. Patient’s Name
(only one patient per form)
__________________________________________________________________________________________
Last
First
Middle Initial
2. Contract Number as shown on your I.D. Card
3. Group Number (as shown on I.D. Card) or Place of
(include any letters, if applicable)
Employment
___________________________________________
___________________________________________
4. Patient’s Date of Birth ______________________
5. Patient’s Sex
Male
Female
MM
DD
YYYY
6. Patient’s Relationship to Contract Holder
Self
Child
Spouse
Other
____________________________________________
(Explain)
7. Contract Holder Information
Name
(as shown on your I.D. card)
__________________________________________________________________________________________
Last
First
Middle Initial
__________________________________________________________________________________________
Street
________________________________________________________________(____)____________________
City
State
Zip Code
Daytime Telephone Number
Ext.
8. Is patient covered under any other group health insurance plan?
(Including any other Blue Cross and Blue Shield Coverage).
YES
NO
If yes, complete the following:
Name of Policy Holder _______________________________________________________________________
Last
First
Middle Initial
Name and Address of
Insuring Company ______________________________________________ I.D. Number__________________
Policy Effective Date
MM
DD
YYYY
Is the patient entitled to Medicare benefits?
Part A
YES
NO
Part B
YES
NO
Medicare Number ________________________
9. Was condition related to:
A. Patient’s Employment
YES
NO
C. Other Accident/Injury
YES
NO
DD
MM
YYYY
B. Auto Accident
YES
NO
________________
If yes, give date of accident or onset of illness:
11. Ordering Physician
10. Diagnoses
(type of illness or injury)
__________
___________–_________________
____________________________________________
(
)
Phone:
____________________________________________
____________________________________________
Last Name
First Name
____________________________________________
____________________________________________
Address
City
State
ZIP
Instructions:
Attach the original bill or statement from the physician or supplier and keep a copy for your records. Make sure the bill contains all required
information. (See back of form for required information.) Sign this form.
I, the undersigned, furnished the above information to enable Blue Cross and Blue Shield to consider this claim for payment, and I certify that such information
is true and correct and that the expenses were incurred by the above named patient. I understand that any payment will be made to me.
Signature _________________________________________________________________ Date ______________________
SEE BACK OF CLAIM FORM FOR EASY CLAIM FILING INSTRUCTIONS
CL-438 (Rev. 6-2002)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business