Health Insurance Claim Form - Blue Cross And Blue Shield Of Illinois
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HEALTH INSURANCE CLAIM FORM
Send Completed Claim Form To:
Blue Cross and Blue Shield of Illinois
P.O. Box 805107
CHICAGO, IL 60680-4112
NOTICE TO ALL PARTIES COMPLETING THIS FORM: It is fraudulent to fill out this form with information
you know to be false or to omit important facts. Criminal and/or civil penalties can result from such acts.
PLEASE PRINT OR TYPE CLEARLY
ID NUMBER -- Copy this from your Blue Cross and Blue Shield Identification Card.
GROUP NUMBER:
IDENTIFICATION NUMBER:
PATIENT INFORMATION -- A separate claim form must be completed for each family member.
PATIENT’S FULL LEGAL NAME (Last, First, Middle Initial)
SEX:
SOCIAL SECURITY NUMBER:
DATE OF BIRTH
Male
Month
Day
Year
___ ___ ___/ ___ ___/ ___ ___ ___ ___
Female
PATIENT IS:
Member
Spouse
Child
OTHER, please explain relationship:
IF CLAIM IS FOR CHILD 19 OR OLDER—IS CHILD:
A full-time student?
Yes
No
Handicapped?
Yes
No
PAYEE:
MAKE PAYMENT TO THE PROVIDER (hospital, doctor etc.), OR
MAKE PAYMENT TO MEMBER, the provider has been paid
MEMBER INFORMATION
MEMBER (POLICY HOLDER) NAME: (As shown on your Blue Cross and Blue Shield
SOCIAL SECURITY NUMBER:
DATE OF BIRTH
ID Card)
Month
Day
Year
___ ___ ___/ ___ ___/ ___ ___ ___ ___
CURRENT ADDRESS:
HOME PHONE:
(__ __ __)__ __ __-__ __ __ __
IF COVERAGE IS THRU
GROUP (EMPLOYER) NAME:
WORK PHONE:
(__ __ __)__ __ __-__ __ __ __
YOUR EMPLOYER, PROVIDE
CLAIM INFORMATION
IS CLAIM FOR AN ACCIDENTAL INJURY?
IS THIS A WORKERS COMPENSATION CLAIM?
DATE OF ACCIDENT:
Yes
No
Yes
No
BRIEFLY DESCRIBE INJURY:
COMPLETE BELOW IF NON-ACCIDENTAL INJURY OR ILLNESS
DATE FIRST TREATED:
BRIEFLY DESCRIBE THE CONDITION(S) FOR WHICH THE PATIENT RECEIVED THESE SERVICES:
(You can usually copy the diagnosis or description of service from the provider bill.)
OTHER INSURANCE INFORMATION
Are there any OTHER medical benefits available to you, your spouse, or your dependents from OTHER Group Insurance, including OTHER Blue Cross and Blue Shield policies,
OTHER Employer, Labor or Professional Organizations, School, etc.?
Yes (provide below)
No
POLICY HOLDER NAME:
SOCIAL SECURITY NUMBER:
___ ___ ___/ ___ ___/ ___ ___ ___ ___
POLICY HOLDER IS:
Member
Spouse
Child
OTHER, please explain relationship:
INSURANCE CARRIER NAME:
POLICY NUMBER:
EFFECTIVE DATE:
ADDRESS:
PHONE NUMBER:
(__ __ __)__ __ __-__ __ __ __
RELEASE OF INFORMATION: I certify that the above information is correct and that the bills attached were incurred by the patient
listed above. I understand that Blue Cross and Blue Shield’s use or disclosure of individually identifiable health information, whether
furnished by me or obtained from other sources such as medical providers, shall be in accordance with the federal privacy
regulations under HIPAA (Health Insurance Portability and Accountability Act of 1996).
Sign
Here _____________________________________________________________________________________________
Date
__________________________
Signature of Member
20479.0305
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