Anthem Claim Form - Flu Shot Only
ADVERTISEMENT
1
2Claim Form — Flu Shot Only
One patient and one provider per claim form, please.
See reverse side for claim filing instructions.
PLEASE PRINT
1. Subscriber no.
2. Group no.
3. Patient name (last, first, initial)
4. Patient birthdate
Month
Day
Year
5. Patient sex
6. Patient relationship to subscriber
7. Subscriber name (last, first, initial)
Male
Female
Self
Spouse
Child
Other
8. Subscriber address (street, city, state, ZIP)
9. Is patient covered by any other Group health benefit plan?
9a. Name of policyholder
Yes
No If no, go to question 10
9b. Name and address of insurance company
9c. Policy no.
10. Name of flu shot clinic that rendered the service
11. Date of service
12. Charge for service. Please attach a copy
of your receipt as proof of payment.
Month
Day
Year
$ _________________
13. Who may we contact if we have questions?
Name ______________________________________________________
Phone no. (
) _____________________
14. I certify to the accuracy and completeness of all information reported by me on this form, and authorize the release of any medical information necessary
to process this claim.
Signature______________________________________________
Date ______/______/______
Please ensure that all fields are completed in full, and that this form is signed and dated. An incomplete form may delay the processing of your
claim. Services other than flu vaccine must be submitted on a separate claim form.
For WellPoint / Source corP uSe only
Diagnosis code: V04.81
Place of service code: 22
*Procedure code: ______________
90656
Flu vaccine, age 3+ years
WGS/STAR Provider Tax ID: 891483333
Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. An independent licensee of the Blue Cross and Blue Shield Association.
82160-Flu Rev. 3/11
® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical