Form Cut0159-1s - Overseas Medical Claim Form (English)

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Federal Employee Program
Clear Form
OVERSEAS MEDICAL CLAIM FORM
ENROLLMENT CODE
IDENTIFICATION NUMBER
1
R
Please see the instructions on the reverse side of this form before completing
PLEASE TYPE OR PRINT.
1. PATIENT INFORMATION
1A. PATIENT’S NAME
1B. PATIENT’S DATE OF BIRTH
Month/Day/Year
First Name, Middle Initial, Last Name
1C. PATIENT’S GENDER
Male
1D. PATIENT'S RELATIONSHIP TO CONTRACT HOLDER
Self
Spouse
Dependent
Female
1E. NAME OF CONTRACT HOLDER
1F. CONTRACT HOLDER'S
DATE OF BIRTH
First Name, Middle Initial, Last Name
Month/Day/Year
1H. EMAIL ADDRESS
1G. CONTRACT HOLDER’S CURRENT MAILING ADDRESS
Street, City, State and Country or ZIP
2. OTHER HEALTH INSURANCE
2A. IS PATIENT COVERED UNDER OTHER HEALTH INSURANCE? If yes, complete items A through K below.
No
Yes
2 .
2C. POLICY OR IDENTIFICATION
2D. NAME OF CONTRACT HOLDER
NUMBER OF OTHER COVERAGE
First Name, Middle Initial, Last Name
2I. CONTRACT HOLDER DATE OF BIRTH
2F. TYPE OF
2E. TYPE
Family
Medical
Yes
No
COVERAGE
Month/Day/Year
OF POLICY
2J. EMPLOYER OF CONTRACT HOLDER
Individual
Dental
Yes
No
2G. EFFECTIVE DATE
2H. TERMINATION DATE
2K. EMPLOYMENT STATUS
Retired Employee
Active Employee
Month/Day/Year
Month/Day/Year
3. DIAGNOSIS
3B. WAS TREATMENT DUE TO WORK RELATED ACCIDENT
3A. DESCRIBE REASON FOR VISIT:
OR CONDITION?
No
Yes
Date of Accident
Time of Accident
3C. COMPLETE FOR CARE RELATED TO ACCIDENTAL INJURIES
AM
PM
Home
Auto
Location
Other
If Other is seleceted, please explain
4. CHARGES
4. CHARGES Please list below: Begin and End date for charges that are being claimed
NUMBER OF
BEGIN DATE
END DATE
TOTAL CHARGES
ITEMIZED BILLS
5. REIMBURSEMENT INFORMATION
5A. CONTRACT HOLDER REIMBURSEMENT INFORMATION
Currency on Bills
Requested Currency
US Dollars
Clear Section
(Skip to 5D to authorize reimbursement to be issued to provider)
5B. SELECT TYPE OF REIMBURSEMENT
Bank Wire
Check
Note: Omission or errors in payment information will result in receipt of a check in US Dollars.
5C. COMPLETE FOR BANK WIRE
Name on Bank Account (Contract Holder)
Bank Name
Complete Bank Address (Street)
Zip Code
City
State
Country
Routing Number (ABA/SWIFT)
Account Number (Local Bank/IBAN)
5D. AUTHORIZATION FOR ASSIGNMENT OF BENEFITS (Benefits can only be assigned to one provider for each claim. Do not complete this section if
requesting a bank wire) I, the undersigned, authorize and request CareFirst BlueCross Blue Shield to make payment for benefits due herein to:
Provider Name
Provider Address (Street)
City
Country
Zip Code
State
Signature of Contract Holder or Spouse
Date
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, which participated in any way in the patient’s care, to release to CareFirst BlueCross BlueShield, any medical information which they
deem necessary to adjudicate this claim. Submission acts as signature for e-Claims
Daytime Telephone Phone Number
Signature of Contract Holder or Patient
Date
CUT0159-1S 5/14
(Including Area Code)

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