Form F7403r07 - Bcbs Subscriber Claim Form

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SUBSCRIBER CLAIM FORM
This claim form must be completed using Black ink.
COPY THE INFORMATION FROM YOUR BLUE
IDENTIFICATION NUMBER
GROUP NUMBER
CROSS AND BLUE SHIELD OF MINNESOTA
MEMBER ID CARD
SUBSCRIBER’S LAST NAME
SUBSCRIBER’S FIRST NAME
SUBSCRIBER’S BIRTHDATE
MO
DAY
YR
PATIENT’S LAST NAME
PATIENT’S FIRST NAME
PATIENT’S BIRTHDATE
MO
DAY
YR
PATIENT’S SEX
PATIENT’S RELATIONSHIP TO SUBSCRIBER
IS CONDITION JOB RELATED?
UNMARRIED
FEMALE
SPOUSE
DEPENDENT
MALE
SELF
YES
NO
SUBSCRIBER’S STREET ADDRESS
CITY
STATE
ZIP CODE
FOREIGN CLAIM?
YES
NO
IS THIS SERVICE RELATED TO:
MO.
DAY
YR.
IF ILLNESS, DATE OF FIRST SYMPTOM
AUTO
IF INJURY or ACCIDENT, DATE OF INJURY or ACCIDENT
ILLNESS
INJURY
MATERNITY
ACCIDENT
IF MATERNITY, DATE OF LAST MENSTRUAL PERIOD
ADMISSION DATE
DISCHARGE DATE
NAME OF ADMITTING PHYSICIAN
NAME OF HOSPITAL
IF HOSPITALIZED:
MO
DAY
YR.
MO.
DAY
YR.
SYMPTOMS AND/OR DIAGNOSIS
NAME OF PROVIDER
PROVIDERS ADDRESS
OTHER COVERAGE INFORMATION
For claims related to an injury or auto accident, please provide the name and address of the other carrier, if
YOU MUST INCLUDE A COPY
applicable.
OF YOUR EXPLANATION OF
BENEFITS,
if you have other health
IDENTIFICATION NUMBER ______________________________GROUP NUMBER___________________
care insurance as primary coverage,
have an auto or worked related injury,
NAME OF INSURANCE COMPANY __________________________________________________________
or have Medicare benefits
ADDRESS ______________________________________________________________________________
Does the patient have other insurance coverage?
Does the patient have Medicare Coverage:
Yes
No
Yes
No
IDENTIFICATION NUMBER ______________________________GROUP NUMBER ________________
MEDICARE NUMBER ______________________________
NAME OF INSURANCE COMPANY _______________________________________________________
Is the patient eligible for Medicare Part A? Yes
No
ADDRESS ____________________________________________________________________________
Is the patient eligible for Medicare Part B? Yes
No
I hereby certify that the statements provided by me are correct and acknowledge that I will refund to Blue Cross and Blue Shield of Minnesota duplicate payments to myself
from other sources because of coordination of benefits. I authorize the provider of services, named above, to release the information requested on this form to Blue Cross and
A person who files a claim with the intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
Blue Shield of Minnesota.
Signature _____________________________________________________________________________________ Date Signed ____________________________________
F7403R07 (11/13)

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