Transportation Claim Form - Blue Cross Blue Shield Of Alaska

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P.O. Box 240609

Transportation Claim Form

Anchorage, AK 99524-0609

If you have any questions about your Transportation Benefits, please refer to your benefit booklet or contact customer service at (800) 508-4722.

See instructions on second page for additional information to complete your claim.

1. PATIENT / MEMBER

Prefix and ID number

Group number

Patient name

Date of birth

(see ID card)

(first, middle, last)

(month/day/year)

Address

City

State

ZIP

Home phone number

Work or alternate phone number

Subscriber name

(first, middle, last)

Does the patient have coverage from any other health plan?

No, skip to section 2

Yes, please attach the Explanation of Benefits (EOB) statement from the primary plan with this claim, and complete the following information.

Name of other health plan

ID number or policy number of other health plan

Phone number of other health plan

2. REASON FOR TRAVEL

Note: Coverage for the following conditions is subject to the benefits and eligibility on your plan

Life-threatening injury or condition

Required surgery that cannot be performed locally

An existing condition that cannot be treated locally

Is this claim due to an accidental injury?

Date of accident

Where did the accident occur?

No, skip to section 3

Yes, complete this section

Home

Work

School

Auto

Other:

How did the accident happen?

Description of injury

3. SIGNATURE

To be accepted, this form must be fully completed, signed, and include the required documentation.

Mail to: Premera Blue Cross Blue Shield of Alaska, P.O. Box 240609, Anchorage, AK 99524-0609

Patient signature

Relationship to patient

Date

(or legal guardian if patient cannot legally consent to services)

(month/day/year)

Self

Other:

Please note: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading

information concerning a matter material to the claim may be prosecuted under state law.

An Independent Licensee of the Blue Cross Blue Shield Association