International Claim Form
Please see the instructions on the reverse side of this form before completing.
Blue Cross and Blue Shield Companies
Send completed form and documentation to:
Service Center
or
are independent licensees of the Blue
P .O. Box 2048
Cross and Blue Shield Association.
or online at
Southeastern, PA 19399
1. Patient Information
1
Member ID
Include all letters and numbers as shown on your Blue Cross Blue Shield identification card
—
A.
1B. Patient’s name
1C. Patient’s date of birth
1D. Patient’s sex
(First, middle initial, last)
Male
Female
MM/DD/YYYY
1E. Name of subscriber
1F. Subscriber’s date of birth
1G. Patient’s relationship
(First, middle initial, last)
to subscriber
Self
Spouse
Child
MM/DD/YYYY
1H. Subscriber’s current mailing address
1I. Patient’s e-mail address
(Street, city, state, and country or ZIP code)
2. Other Health Insurance
Is the patient covered under other health insurance, including Medicare A or B?
—
Yes
No
If yes, complete 2A through 2K below.
2
Name and address of other insuring company
A.
2
Type of policy
2
Effective date
2D. Termination date
2E. Policy or identification number
B.
C.
of other coverage
Family
Individual
MM/DD/YYYY
MM/DD/YYYY
2
Type of coverage
2
Name of subscriber
2
Date of birth
F.
G.
H.
Hospital:
Yes
No
Medical:
Yes
No
Mental illness:
Yes
No
MM/DD/YYYY
2
Employer of subscriber
2
Employment status
I.
J.
Active employee
Retired employee
2
If patient is covered under Medicare, complete the following:
Medicare Part A:
Yes
No
Medicare Part B:
Yes
No
K.
Effective date ________________ Effective date _________________
3. Diagnosis
3
Describe illness, injury, or symptoms requiring treatment and onset date of symptoms or injury.
—
A.
3
Was patient’s treatment due to a work-related accident or condition?
Yes
No
B.
3
Complete for care related to accidental injuries
C.
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.
4. Charges
— Use a separate line to list each type of service or provider and attach itemized bills for all services.
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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5. Payee
— Select one of the following payment options:
Option
Make payment to subscriber; provider has been paid.
A.
Select your payment preference:
Check – US Dollar
Electronic Funds Transfer – US Dollar
Electronic Funds Transfer – Currency on itemized bill(s)
If you want to receive an electronic funds transfer provide the following:
Subscriber name as it appears on bank account: _____________________________________________________ Bank name: _____________________________________________
Bank’s Physical Address: _____________________________________________________________________________________________________________________________________
Account # /IBAN: ________________________________________________________________________Routing # / ABA / BIC / SWIFT: _______________________________________
Option
Make payment to provider (hospital, doctor), if appropriate. Please complete and sign to authorize direct payment to provider.
B.
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 the subscriber’s Blue Cross and Blue Shield company:
Name of provider _______________________________________ Signature of subscriber or spouse ________________________________________________ Date _________________
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 company 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 company 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 company’s Notice of Privacy Practices.
Signature of subscriber or patient
________________________________________________________________________________________ Date _________________________