Community Health Education - Reimbursement Form
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1
2COMMUNITY HEALTH EDUCATION
REIMBURSEMENT FORM
–IMPORTANT–
Please read and follow the instructions located on the front and back of this form. Complete all unshaded areas of the form by printing clearly
with a non-erasable ink pen. This form will be returned to you if it is not complete. Anthem Blue Cross and Blue Shield will send reimbursement
to the subscriber when approved. Please expect 6-8 weeks to process once Anthem Blue Cross and Blue Shield receives this form.
1. Member’s name:
2. Member’s date of birth:
3. Member’s Identification Number as shown on ID card.
(last)
(first)
(m.i.)
Mo.
Yr.
Please include the 3-letter prefix.
____ ____ ____ _______________________________
4. Member’s sex:
5. Group (Employer) name:
Male
Female
Group # (located on your id card): ____________________________________________________________________________
6. Subscriber’s name (if other than member): _______________________________________________________________________
(last)
(first)
(m.i.)
7. Subscriber’s address:
Street _________________________________________________________________ ______
City ______________________________________________ State_________ Zip_________________
Check box if new address
Telephone ____________________________________ ____
8. Participating Vendor:
9. Participating Vendor ID# (please affix sticker):
Name __________________________________________________________________
Street _________________________________________________________________
#83-9999999-NH-01
City __________________________________________ State____ Zip___________
DO NOT WRITE IN SHADED AREAS
11. Place of ser-
12. Class Name:
10. Date of Class
vice:
(Mo./Day/Yr.):
16. Instructor/Class leader:
14. Amount
15. Total number
13. Diagnosis
From
To
paid by
of sessions:
0L
Code:
Member:
Name: _________________________________________
799.89
Check box if member completed the program
$
.
(allowed to miss maximum of one class per series)
17. Type of class:
18. Procedure Code
19. We authorize the release to Anthem Blue Cross and Blue Shield of any information necessary to
process this request for reimbursement. We agree to the information written above, and verify that the
(please check ONLY ONE category)
member completed the program.
S9453
Smoking Cessation
S9452
Nutrition Education
X_________________________________________________________________________________________
S9449
Weight Management
(Vendor signature)
S9454
Stress Management
S9451
Physical Activity
20. I authorize the release to Anthem Blue Cross and Blue Shield of any information necessary to process
this request for reimbursement. I agree to the information written above and verify that I completed the
S9442
Childbirth Education
program.
S9444
Parenting Education
21. Date form completed
X_________________________________________________________________________________________
(Member signature)
The persons signing this form are advised that the willful entry of false or fraudulent information renders you liable to be withdrawn from this community health educa-
tion program.
–Thank you –
An independent licensee of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, Inc.
® Registered marks of the Blue Cross and Blue Shield Association.
0547NH (4/08)
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