Subscriber Claim Form For Services Received Outside California

Subscriber Claim Form for Services Received Outside California

This form is used to submit claims directly to Blue Shield of California or Blue Shield of California Life & Health Insurance

company when you’ve received covered services outside of California. You should only use this form when you are

certain that the provider of service has not and will not submit a claim for you. Duplicate claims will be rejected, and

may delay payment of the claim if submitted by both you and your provider. If you have any questions about this

form, call the Customer Service number on your Blue Shield ID card, or call (877) 655-2583.

Important instructions for subscriber submitted claims

• Use a separate form for:

Please include a copy of your bill/claim that includes

– Each member of your family

all of the following information:

– Each different provider of service

• Date of service

– Each itemized bill

• Charges for each individual procedure

• Diagnosis code(s)

• Please print or type.

• Fill in all items completely.

• Procedure code(s)

• Sign your name in the space provided.

• Place of treatment

Not following these instructions may result in your

• Provider name

claim being delayed or returned to you.

• Provider tax ID

Subscriber name

Alpha prefix Subscriber ID number

Group number

(Last name, First, MI)

Mail address – Street

City

State ZIP

Is address new?

c Yes

c No

Name of patient

Date of birth Month

Day

Year

(Last name, First, MI)

Patient’s gender c Male

c Female

Relationship to subscriber c Self

c Spouse/domestic partner

c Child

Describe briefly patient’s illness or injury, and if injury, how it occurred

Patient was treated for

Date of injury, onset

Month

Day

Year

c Injury

c Illness

c Pregnancy

of illness, or pregnancy

If yes, coverage effective date

Month

Day

Year

Is patient retired? c Yes

c No

If yes, policy identification number

Does patient have other health coverage? c Yes

c No

Name of insuring company

Effective date

Address of insuring company

Type of plan

c Group

c Individual

Name of policy holder

Sex

Date of birth Name of employer

If yes, patient’s date of birth

Was condition related to employment? c Yes

c No

Part A effective

Part B effective

Does patient have Medicare? c Yes

c No

Subscriber’s signature

I certify that the foregoing information is accurate and complete, and authorize the release of any medical

information necessary to process this claim.

X ____________________________________________________________________________________________ Date ____________________

Please send this completed form to: Blue Shield of California, P.O. Box 1505, Red Bluff, CA 96080

Subscriber Claim Form For Services Received Outside California - Bcbs

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