Form C-3344 - Member Claim Form
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MEMBER CLAIM FORM
A SEPARATE CLAIM FORM MUST BE SUBMITTED FOR EACH PATIENT WHEN SENDING BILLS TO WELLMARK BLUE CROSS AND BLUE SHIELD OF SOUTH DAKOTA
PLEASE REFER TO THE INSTRUCTION ON THE BACK OF THIS FORM WHEN FILING YOUR CLAIMS.
Identification Number (as indicated on your identification card including the three-digit prefix
Group Number
Patient's Information
Patient's Last Name
Complete First Name
MI
Date of Birth
/
/
Gender
Patient's Relationship to Policy/Certificate Holder
Male Female
Self
Spouse
Child
Other (Specify)
Description of illness or injury requiring treatment
Date Illness Began
/
/
Was this an accident?
If yes, date of accident
Was this an automobile accident?
Was the illness/accident related to employment?
Yes
No
/
/
Yes
No
Yes
No
If yes, what school?
Was patient a full time Student?
Yes
No
Other Insurance - This part must be completed in full before we can determine responsibilities for you claim
Do you have Medicare? Part A: No Yes; Effective Date ____/____/_______ Part B: No Yes; Effective Date ____/____/_______
If yes, please file the claim with Medicare first. Then submit a copy of your Explanation of Benefits with this form.
Is the patient covered by other insurance? Yes
No
if yes, and the policy is with a group (such as through an employer or Farm Bureau), please complete the following section.
Name of insured policyholder
Name and address of insured's employer
Name and address of other insurance company
Policy Number (other insurance co.)
Type of Coverage
Has the other insurance company paid?
If yes, please submit a copy of their payment information with
Single
Family
Yes
No
this form.
Policy/Certificate Holder Information
Policy/Certificate Holder's Last Name
Complete First Name
MI
Policy/Certificate Holder's Employer
Policy/Certificate Holder's Address
City
State
Zip Code
Date of Birth
/
/
I certify the above is complete and correct and that I am claiming benefits for charges incurred by the patient named above. I authorize any
health care provider to release medical records to Wellmark Blue Cross and Blue Shield of South Dakota when reasonably related to the health
care claim submitted. If any law of regulation requires additional authorization for release of medical records, I will give this authorization.
Policy/Certificate Holder's Signature: _________________________________________________________ Date _____/_____/______
Other Services and Supplies not Filed by Provider or Hospital (Attach a legible copy of original receipts)
These may include office visits, hospital visits, physical therapy, diabetic supplies, ambulance services, medical appliances, etc.
If services were rendered outside the USA, please
Country
Currency Used
indicate:
Date of Service
Description of Service / Supplies
Diagnosis or Symptons you Sought Treatment For
Charge
(MM/DD/YYYY)
/
/
/
/
/
/
/
/
/
/
Provider Information
Name
Tax ID
NPI
Address
City
State
Zip Code
Place of Service
C-3344 2/15
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