Blue Cross Blue Shield Association Medical Claim Form 1
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This form is provided by Blue Cross Blue Shield of Texas.
Dallas, Texas 75266-0044
Each item on this form needs to be completed.
Please Print or TypeInstructions for completion are listed on the reverse side.
Insured/Subscriber Name (Last, First, Middle Initial)Group Number Insured/Subscriber Identification Number (from ID card)
Mailing Address Patient's Full Name (Last, First, Middle)
City & State Zip Code Patient's SexPatient's Date of BirthMonthDayYear
Female_____ /_______ /____
Insured EmployedDate of Retirement Patient's Relationship to Insured
Month Day Year
Injury — Date of Accident:______ /______ /______
Illness — Date of First Symptom:______ /______ /______
Pregnancy — Date of Conception:______ /______ /______
Preventive — Date of Service:______ /______ /______
Describe:Diagnosis, Symptoms of Illness or Injury or explain Preventive or Routine care received.
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