Fillable Form 4f1-19049 - Health Benefits Claim Form (English) printable pdf download

CLEAR FORM

Health Benefits Claim Form

Please review the instructions on the

reverse side of this form before completing.

ENROLLMENT CODE

IDENTIFICATION NUMBER

PATIENT

INFORMATION

PATIENT’S DAT E OF BIRTH

PATIENT’S NAME (First, Middle Initial and Last)

PATIENT’S SEX

Month/Day/Year

Male

Female

PATIENT’S RELATIONSHIP

DATE OF BIRTH

NAME OF ENROLLEE OR POLICY HOLDER (First, Middle Initial and Last)

TO ENROLLEE

Month/Day/Year

Self

Spouse

Child

If the patient’s last name is different from the enrollee’s, please attach a statement explaining the relationship.

ENROLLEE’S CURRENT ADDRESS (Street, City, State and ZIP Code) CHECK IF NEW ADDRESS

EMAIL ADDRESS

PLEASE COMPLETE INFORMATION BELOW ONLY IF IT HAS CHANGED SINCE YOU LAST GAVE IT TO US. IF NO CHANGES, GO TO #5.

OTHER HEALTH

Is the patient covered by additional health insurance through an employer, a group such as a professional organization, or any other

group health insurance, including other Blue Cross and/or Blue Shield Coverage?

Yes

INSURANCE

If yes, please complete this section.

NAME AND ADDRESS OF INSURING COMPANY (Street, City, State and ZIP Code)

EFFECTIVE DATE

TERMINATION DATE

Month/Day/Year

NAME OF POLICY HOLDER (First, Middle Initial and Last)

IDENTIFICATION NUMBER (Include all letters

DATE OF BIRTH

AND HIS/HER EMPLOYER

and numbers)

Month/Day/Year

PLEASE COMPLETE THIS SECTION ON MEDICARE REGARDLESS OF THE PATIENT’S AGE

MEDICARE

If you are covered by a Medicare HMO/Prepaid Plan, please leave Sections A and B Blank

MEDICARE HMO/

If the patient is eligible for Medicare due to End-Stage

MEDICARE PART A

MEDICARE PART B

Yes

(Hospital Insurance)

(Medical Insurance)

PREPAID PLAN

Renal Disease, please indicate the beginning date of

If yes, effective date

renal treatment or transplant.

Month/Day/Year

Yes

Is the patient

If the patient is retired from the Federal Government, but still employed, please

EMPLOYMENT

presently employed?

complete the following:

NAME AND ADDRESS OF COMPANY OR GOVERNMENT AGENCY

(Street, City, State, and ZIP Code)

Describe illness, injury or symptoms requiring treatment. If illness, injury or symptoms are related to an accident,

DIAGNOSIS

please complete A, B and C.

DATE OF ACCIDENT

TIME

LOCATION

Month/Day/Year

At Home

Motor vehicle accident

Was the accident caused by someone else?

At Work

If so, what state

Yes

Other

Please explain

CHARGES

Please list below those charges that you are claiming for benefits. Use a separate line for each type of service or provider.

PLEASE ATTACH ITEMIZED BILLS

NAME OF PROVIDER MAKING CHARGE

DESCRIPTION OF CHARGE

DATE OF SERVICE OR PURCHASE

(Doctor, Hospital, etc. Two or more bills from the same

(Office Visits, Therapy from Mental

(If there is only one date, show it under “FROM”.)

provider may be entered on one line if they are for the

Conditions, etc.)

FROM

CHARGE

same type of service.)

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, which participated in any way in my care, to release to the Blue Cross and/or Blue Shield Plan any medical information which they deem necessary to adjudicate this claim.

SIGNATURE

Signature of Enrollee or Patient

Date

Daytime telephone number

including area code

Failure to sign this claim form may delay processing.

4F1-19049 - F Rev. 10/14