Claim Form For All Health Care Services printable pdf download

Claim Form

For All Health Care Services

P.O. Box 26623

Member Services: 358-7390 (Richmond Area)

Richmond, Virginia 23261

Outside Richmond: 1-800-421-1880

PLEASE PRINT OR TYPE

This claim form is designed to help you, the member, or your Health Care Professional, ﬁle your itemized health care related bills. Most

Health Care Professionals will ﬁle claims for you. If, for some reason, your Health Care Professional cannot ﬁle the claim on your behalf,

you may use this form to claim beneﬁts. All claims must be submitted within 30 days from the date the service is rendered. Please review

your health care bills at least once a month to assure timely ﬁling of your claims. For prompt service, please follow these steps:

1. Assemble all itemized health care bills.

2. Separate your bills for each family member.

3. Complete a separate claim form for each family member.

When ﬁling services for:

please attach:

Doctors

__________________itemized bill or local Blue Shield form or AMA form

Dentists

__________________itemized bill, Blue Shield form, or local ADA form

Hospital

__________________itemized bill, hospital form, or the UB82 form

Prescription Drugs

__________________itemized bill

Home Care Equipment

__________________itemized bill and letter of medical necessity from your physician

NOTE: If you have Medicare coverage, you must attach your Medicare Explanation of Beneﬁts along with your itemized bills.

An itemized bill must include the patient name, name of Health Care Professional, address, professional status, date of each service,

descriptions and charge for each service (prescription number if drugs).

1. Patient’s name (Last, First, M.I.)

2. Patient’s Date of Birth

3. Subscriber Identiﬁcation Number (include any letters)

month

day

year

4. Patient’s Address (street, city, state & zip code)

5. Patient’s relationship to Subscriber

6. Patient’s sex

(1)

(2)

(3)

(1)

(2)

self

spouse

child

other

male

female

7. Was condition related to

8. Was treatment required

9. Date patient ﬁrst consulted doctor for

this condition: (month/day/year)

(1)

(2)

If injury, give date:

employment

auto accident

for illness

injury

15. I certify that the information I have given is accurate to the

10. Diagnosis or symptoms

11. Have you paid for itemized services

best of my knowledge and that I, as the Participant, am

Yes

claiming beneﬁts only for charges incurred by the patient

identiﬁed above. I authorize any medical professional, med-

12. Does patient have other

13. If “yes,” give policy number

group policy

Check one

ical care institution, or any other provider of health care

insurance coverage

individual policy

services or supplies to furnish to HealthKeepers, Inc. infor-

Yes

mation concerning services or supplies provided to me for

14. If you have other coverage, give name of Subscriber, name and address of insurance company,

the purposes of review, investigation or payment of a claim.

employer providing group coverage

This authorization is valid for the duration of coverage. I

understand that a copy of this authorization is available to

me or my authorized representative upon request.

Signature: ____________________________________

Date: ________________________________________

Beneﬁts for covered services rendered outside the Anthem HealthKeepers primary service area may be paid to the policyholder or the provider of services.

REQUIRED PROVIDER INFORMATION

Provider Name: __________________________________________________________________________________________________________________

Address: ____________________________________________________________________________________________________________________________

City:________________________________________________________________________ State:_________________________ Zip:______________________

Type of Provider:

MD/DO

DDS

Podiatrist

Clinical Psychologist

Hospital

Other (must specify) ___________________________

State Professional License #________________________________________ IRS Tax ID or Social Security #_________________________________________

Beneﬁts for covered services rendered outside the HealthKeepers, Inc. service area are limited to emergencies in which care is required immediately or unexpectedly.

Elective care or care required as a result of circumstances which could reasonably have been foreseen prior to departure from the service area is not covered.

Policyholder’s Signature: __________________________________________________________________________________________________________

Independent licensee of the Blue Cross and Blue Shield Association.

® Registered marks Blue Cross and Blue Shield Association.

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