Bluecard Worldwide International Claim Form printable pdf download

BlueCard Worldwide

International Claim Form

Blue Cross and Blue Shield Plans are

independent licensees of the Blue

Please see the instructions on the reverse side of this form before completing. Please type or print.

Cross and Blue Shield Association.

Send completed form to:

BlueCard Worldwide Service Center

P .O. Box 72017

Richmond, VA 23255-2017 USA

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1. Patient Information

Alpha prefix Identification number

Copy this from your Blue Cross Blue Shield identification card.

Patient’s name

Patient’s date of birth

Patient’s sex

(First, middle initial, last)

Male

Female

MM/DD/YYYY

Name of subscriber

Subscriber’s date of birth

Patient’s relationship

(First, middle initial, last)

to subscriber

Self

Spouse

Child

MM/DD/YYYY

Subscriber’s current mailing address

(Street, city, state, and country or ZIP code)

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2. Other Health Insurance

Is the patient covered under other health insurance, including Medicare A or B?

Yes

If yes, complete 2A through 2K below.

Name and address of other insuring company

Type of policy

Effective date

2D. Termination date

2E. Policy or identification number

of other coverage

Family

Individual

MM/DD/YYYY

Type of coverage

Hospital:

Yes

Name of subscriber

Date of birth

Medical:

Mental illness:

Yes

MM/DD/YYYY

Employer of subscriber

Employment status

Active employee

Retired employee

If patient is covered under Medicare, complete the following:

Medicare Part A:

Yes

Medicare Part B:

Yes

Effective date

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3. Diagnosis

Describe illness, injury, or symptoms requiring treatment and onset date of symptoms or injury.

Was patient’s treatment due to a work-related accident or condition?

Yes

Complete for care related to accidental injuries

Date of accident

Location:

At home

Auto

Other

Time of accident

If the accident was caused by someone else, attach a statement describing the accident.

— Use a separate line to list each type of service or provider and attach itemized bills for all services.

4. Charges

4A. Name and address of

4B. Type of provider

4C. Description of service

4D. Dates of service

4E. Charges

or purchase

provider making charge

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— Select one of the following payment options:

5. Payee

Make payment to subscriber; provider has been paid.

1. Currency – Please check your preference for payment:

Currency on itemized bill(s)

U.S. dollars

2. Payment Method – Please select your preference for how to receive your payment:

Check (Provide current telephone number)

Bank Wire. If you want to receive a bank wire provide the following:

Subscriber name as it appears on bank account:

Bank name:

Bank’s Physical Address:

Account #:

ABA#

*International Bank Account (IBAN) #:

*Bank Identifier Code (BIC/SWIFT)

* Required for bank wires to European Union countries.

Make payment to provider (hospital, doctor), if appropriate. Please complete and sign to authorize direct payment to provider.

I, the undersigned, authorize and request payment for benefits due herein to be made to the following provider of services, if such direct payment is deemed appropriate by

Blue Cross and Blue Shield:

Name of provider

Signature of subscriber or spouse

Date

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6. Signature

I certify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named above. Authorization is

hereby given to any provider of service, that participated in any way in the patient's care, to release to the subscriber's Blue Cross and Blue Shield Plan and its business

associates in any country any medical or other personal information that they deem necessary to provide service or adjudicate this claim, recognizing that applicable law

concerning personal information may differ among countries. Authorization is also given to the subscriber's Blue Cross and Blue Shield Plan and its business

associates in any country to collect, use or release any medical or other personal information that they deem necessary to provide service, adjudicate a claim or as

otherwise described in such Blue Cross and Blue Shield Plan’s Notice of Privacy Practices.

Signature of subscriber or patient

Date