Member Claim Form Page 2
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1
2SECTION IV: Services and Supplies To Be Considered For Reimbursement
These may include ambulance services, medical appliances, diabetic supplies, glasses and/or contact lenses or out-of-network services.
BCBSNC requires that procedure codes and diagnosis codes on the itemized receipt be supplied by the provider of
the service. Claims or itemized receipts received without the information below will be RETURNED.
Please indicate where services were rendered if not in North Carolina:
Country:
Currency Used:
Diagnosis Codes or Symptoms You
Date of Service
Procedure Codes or Description of Service/Supplies
Charge
(MM-DD-YY)
Sought Treatment For
01-05-07
Office Visit
Cold and Flu Symptoms
54.00
EX MPLE:
Enclose a copy of your receipts for these services.
SECTION V: Private Duty Nursing
Date of Service
Indicate
Hours
Name of Nurse
License Number
Charge
RN, LPN or CN
Worked
(MM-DD-YY)
03-10-07
Ms. Jane M. Doe
LPN
123456
8
160.00
EX MPLE:
SECTION VI: Mailing Information
DID YOU REMEMBER TO:
MAIL THIS FORM, ITEMIZED RECEIPTS AND
•
Use blue or black ink to complete the form?
EXPLANATION OF BENEFITS (if applicable) TO:
•
Attach the Explanation of Benefits, if applicable?
Blue Cross and Blue Shield of North Carolina
•
Attach itemized receipts?
P.O. Box 35
•
Provide your signature below?
Durham, NC 27702
•
Keep a copy of this form and your receipts?
I certify that the information on this form is correct and the expenses incurred were necessary for the services filed.
Daytime
Phone
Signature:
Date:
Number:
Print & Sign Document
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