Medical Member Claim Form - Blue Cross - California

Medical Member Claim Form

SEE REVERSE SIDE FOR COMPLETE CLAIM MAILING INSTRUCTIONS

Please use a separate claim form for each patient. Your cooperation in completing all items on the claim form and attaching all required

documentation will help expedite quick and accurate processing.

PLEASE TYPE or PRINT

PATIENT INFORMATION

SUBSCRIBER INFORMATION (on member ID Card)

NAME

Last

First

Middle Initial

MEMBER ID

GROUP NO.

BIRTHDATE

SEX

RELATION TO SUBSCRIBER

NAME

Last

First

Middle Initial

M

F

Self

Spouse

Son

Daughter

DOES THE PATIENT HAVE OTHER HEALTH INSURANCE COVERAGE?

ADDRESS

YES

NO

NAME OF OTHER HEALTH INSURANCE COMPANY

CITY

STATE

ZIP CODE

POLICY NO.

HOME PHONE NO.

WORK PHONE NO.

(

)

(

)

MEDICAL INFORMATION

HEALTH CARE SERVICES: Use this section to report any COVERED health service which has not already been reported to this

Anthem Blue Cross Plan by the provider of service (the physician, clinical, ambulance company, private duty nurse, etc.) Attach itemized bill

or photocopy. Please be sure that duplicate bills are not submitted.

Was this medical expense the result of an accident? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YES

NO

Was this condition or injury job related? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YES

NO

Have you filed for Workers’ Compensation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YES

NO

On what day did this injury or accident occur?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Month:___

Day:___

Year:___

Have you been treated for the same condition within the last 24 months?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YES

NO

If yes, indicate date you were last treated: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Month:___

Day:___

Year:___

DATE OF SERVICE

PROVIDER OF SERVICE

SERVICE RENDERED

ILLNESS OR DIAGNOSIS

TOTAL

(Mo/Day/Yr)

(Name of Doctor, Lab, Amb. Co., etc.)

(Office Visit, X-ray, etc.)

If the bill is from a Licensed Clinical Social Worker; Marriage, Family and Child Counselor; Audiologist; or Occupational,

GRAND

Physical, or Speech Therapist; what is the name of the physician who ordered the service?

TOTAL

$

Dr.

I certify that the information on this Member Claim Form is true and correct to the best of my knowledge. I authorize the release of any medical information

necessary to process this claim.

X

SIGNATURE OF SUBSCRIBER

DATE

Anthem Blue Cross is the trade name of Blue Cross of California. An independent licensee of the Blue Cross Association.

® Registered Mark of the Blue Cross Association

MCAFR1040C

(12/07)