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Medical Claim Form

This document provides instructions for submitting a claim to Blue Shield of California. It begins with identifying information to include the subscriber's name, number, address, and other demographic details. It also requests information about the patient's condition, treatment, and any other insurance coverage. The final section requires the subscriber's signature to authorize the release of medical information. Exceptions are outlined for claims with primary Medicare coverage or services rendered outside the US. Submitting separate claims for each family member, provider, and itemized bill is emphasized. Failure to follow the instructions may delay or result in the return of the claim.

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Akash Srivastava
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63 views1 page

Medical Claim Form

This document provides instructions for submitting a claim to Blue Shield of California. It begins with identifying information to include the subscriber's name, number, address, and other demographic details. It also requests information about the patient's condition, treatment, and any other insurance coverage. The final section requires the subscriber's signature to authorize the release of medical information. Exceptions are outlined for claims with primary Medicare coverage or services rendered outside the US. Submitting separate claims for each family member, provider, and itemized bill is emphasized. Failure to follow the instructions may delay or result in the return of the claim.

Uploaded by

Akash Srivastava
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Subscribers Statement of Claim

Send this claim to: Blue Shield of California, P.O. Box 272540, Chico, CA, 95927-2540.
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.

Important instructions
Exceptions:
Primary Medicare coverage
A. Submit claim to Medicare first.
B. Complete boxes 1 and 4 only.
C. Attach your explanation of Medicare benefits form and a copy
of itemized services to this claim and send all to Blue Shield.

Use a separate form for:


A. Each member of the family
B. Each different provider of service
C. Each itemized bill
Print or type
Fill in all items completely
Sign your name in the space provided
Failure to comply with these instructions may result in your
claim being delayed or returned to you.

Foreign claims
Any services rendered outside of the United States or its territories
must include the US currency exchange rate or value and the
translation for all billed services.

1
Subscriber name (Last, First, MI)

Subscriber number

Mail address

Group number

City

State

ZIP

Is address new?
c Yes c No

Date of birth (mo/day/yr)

Gender
c Male
c Female

Relationship to subscriber
c Self c Spouse
c Child

Describe briefly patients illness or injury and, if injury, how it occured

Patient was treated for


c Injury c Illness c Pregnancy

Date of injury, onset of illness or pregnancy

Is patient retired?
c Yes c No

If Yes, effective date

3
Does patient have other health
coverage? c Yes c No

If Yes, policy ID number

Name of insuring company

Effective date

Address of insuring company


Name of policy holder

Type of plan
c Group c Individual
Gender
c Male
c Female

Date of birth
(mo/day/yr)

Name of employer

4
Was condition related to employment?
c Yes c No

Does patient have Medicare?


c Yes c No

If Yes, date of birth


(mo/day/yr)

Part A effective date

Part B effective date

Subscribers 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 _______________

blueshieldca.com

An Independent Member of the Blue Shield Association

Patients name

CLM14850 (1/10)

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