Form C-12133-Emp - Subscriber'S Statement Of Claim - Blue Shield Employee Of California
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1Mailing Address:
P. O. Box 272580, Chico, CA 95927-2580
BLUE SHIELD USE ONLY
SUBSCRIBER’S STATEMENT OF CLAIM - BLUE SHIELD EMPLOYEE
This form is to be used ONLY when the Provider of Service does not submit your claim directly to Blue Shield.
Check with the Provider to be sure no claim has been submitted.
Duplicate claims will not only be rejected but may delay payment of the original claim.
•
EXCEPTIONS
*USE A SEPARATE FORM FOR:
•
A. EACH MEMBER OF THE FAMILY
PRIMARY MEDICARE COVERAGE —
B. EACH DIFFERENT PROVIDER OF SERVICE
A. Submit claim to Medicare first.
C. EACH ITEMIZED BILL
B. Complete Boxes 1 and 4 only.
C. Attach your Explanation of Medicare
•
PRINT OR TYPE
Benefits form and a copy of itemized services
•
FILL IN ALL ITEMS COMPLETELY
to this claim and send all to Blue Shield.
•
SIGN YOUR NAME IN THE SPACE PROVIDED
•
FOREIGN CLAIMS —
Failure to comply with these instructions may
Any services rendered outside of the United States
result in your claim being delayed or returned
or its territories must include the US currency
to you.
exchange rate or value and the translation for all
billed services.
SUBSCRIBER NAME (LAST NAME, FIRST, MI)
SUBSCRIBER NUMBER
GROUP NUMBER
1
MAIL ADDRESS — STREET
CITY
STATE
ZIP CODE
IS ADDRESS NEW?
YES
NO
NAME OF PATIENT (LAST NAME, FIRST NAME, MIDDLE INITIAL)
DATE OF BIRTH
PATIENT’S SEX
RELATIONSHIP TO SUBSCRIBER
2
Month
Day
Year
Male
Female
Self
Spouse
Child
DESCRIBE BRIEFLY PATIENT’S ILLNESS OR INJURY AND, IF INJURY, HOW IT OCCURRED
PATIENT WAS TREATED FOR
IS PATIENT RETIRED?
EFFECTIVE DATE
DATE OF INJURY; ONSET OF
If Yes:
ILLNESS OR PREGNANCY
Month
Day
Year
INJURY
ILLNESS
PREGNANCY
YES
NO
DOES PATIENT HAVE OTHER HEALTH
IF YES, POLICY IDENTIFICATION NO.
NAME OF INSURING COMPANY
EFFECTIVE DATE
3
COVERAGE?
YES
NO
ADDRESS OF INSURING COMPANY
TYPE OF PLAN
GROUP
INDIVIDUAL
NAME OF POLICY HOLDER
SEX
DATE OF BIRTH
NAME OF EMPLOYER
WAS CONDITION RELATED
DOES PATIENT HAVE MEDICARE?
PATIENT’S DATE OF BIRTH
PART A EFFECTIVE DATE
PART B EFFECTIVE DATE
4
If Yes:
TO EMPLOYMENT
Month
Day
Year
Month
Day
Year
YES
NO
YES
NO
SUBSCRIBER’S SIGNATURE
*NEED ADDITIONAL CLAIM FORMS?
I certify that the foregoing information is accurate and complete, and authorize
1-800-443-5005
the release of any medical information necessary to process this claim.
IN CALIFORNIA:
1-209-367-2800
OUT OF CALIFORNIA:
X
DATE:
Customer Service
BLUE SHIELD OF CALIFORNIA
REQUEST CLAIM
BLUE SHIELD OF CALIFORNIA
P.O. Box 272580
SEND THIS CLAIM TO:
INFORMATION FROM:
P.O. Box 272580
Chico, CA 95927-2580
Chico, CA 95927-2580
C-12133-EMP (1/06)
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