Form Ain-300 - Major Medical Claim Form
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Major Medical Claim Form
Mail to:
Anthem Blue Cross and Blue Shield
P.O. Box 37010
Louisville, KY 40233-7010
1P
Read instructions on reverse side.
A separate claim form must be filed for each patient.
About The
(Complete even if employee is not the patient)
Employee’s name
Employee’s identification number
Account number
Employee
(From ID card)
(From ID card)
(From ID card)
Last
First
Employee’s address
Check if
address
is new
Street
City
State
Zip
About The
Patient’s first name
Patient’s last name if
Patient’s birthday
(As shown on our records)
different from employee’s
Month
Day
Year
Patient
Patient’s sex
Male
Female
Patient is:
The employee
Your spouse
Your child
About The
Describe the illness, accident, or condition
__________________________________________________________________________________________________________________________
Claim
__________________________________________________________________________________________________________________________
Accidents:
Were the services used
If “Yes” was the accident:
as the result of an accident?
an auto accident
at work
Yes
No
at home
other _______________________
__________________________________________________________________________________________________________________________
When did the accident happen?
Month ______ Day ______ Year ______ Time ______ : ______
AM
PM
__________________________________________________________________________________________________________________________
Other Coverage:
Does patient have other group health insurance?
Yes
No
__________________________________________________________________________________________________________________________
If “Yes” and you have not previously answered the questions below, please complete. If you have already answered them, please ignore.
Policyholder: ______________________________________________________
Birthdate of Policyholder: __________________________________
Name and address of the other insurance company: ________________________________________________________________________________
__________________________________________________________________________________________________________________________
Policy or certificate number: ___________________________________________ Effective date of other insurance: ___________________________
Payments To
Is any payment on this claim to go to whoever provided services to you?
Yes
No
If so, who?
If you received services from a preferred provider, the provider will file your claim.
Others
Name:
Address:
_______________________________________________
_________________________________________________________________________
_______________________________________________
_________________________________________________________________________
Signatures
Both parts of this section must be signed or we will not process the claim.
A person who knowingly, and with intent to defraud an insurer, files a statement of claim containing any false, incomplete or
misleading information commits a felony.
I have furnished the information on this form so that Anthem
If I have indicated that any payments on this claim are to be made to
Insurance Companies, Inc. may consider this claim. By signing below,
others, I authorize Anthem Insurance Companies, Inc. to make those
I certify that the information is correct and that the expenses were
payments directly. If any money is paid on this claim in error, or not
incurred by the patient named above.
authorized by the insurance contract, I agree to return it to Anthem
Insurance Companies, Inc.
________________________________________________________
________________________________________________________
Employee’s signature
Date
Authorization to Release Information:
I authorize any insurance company, employer, organization, or provider of services to release any information related to this
claim to Anthem Insurance Companies, Inc. or its authorized contractor before or after payment.
__________________________________________________________
__________________________________________________________
Patient’s signature (even if employee) or parent or guardian of minor
Date
AIN-300 Rev. 6/01
An independent licensee of the Blue Cross and Blue Shield Association.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc.
® Registered marks Blue Cross and Blue Shield Association.
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