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Blue Cross Blue Shield Association Medical Claim Form 1

This form is provided by Blue Cross Blue Shield of Texas.

Blue Cross Blue Shield Association Medical Claim Form 1
Blue Cross Blue Shield Association Medical Claim Form 1
P.O. Box 660044
Dallas, Texas 75266-0044
Each item on this form needs to be completed.
Please Print or Type Instructions 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 Sex Patient's Date of Birth Month Day Year
Male
Female _____ /_______ /____
Insured Employed Date of Retirement Patient's Relationship to Insured
Month Date Year
Ye s
No
Retired
//
1.
Self 2.
Spouse 3.
Child 4.
Other (explain) ____________________
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.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Was Illness or Injury work connected
Ye s
No Name and Address of Employer
__________________________________________________
If Injury, was motor vehicle involved
Ye s
No
__________________________________________________
Is patient covered under any other Health Benefits Plan (besides Medicaid, Medicare or CHAMPUS)
Ye s
No
Insuring Co.____________________________________ Policy # ______________________ Month Day Year
Address_______________________________________ Effective Date of Coverage ______/______/______
Employer______________________________________
Sex
Male
Female Birthdate ______/______/______
(Insured) (Insured)
Insured________________________________________
Relationship to Patient_________________________________
If the other coverage is primary, attach the other insurance company's Explanation of Benefits
Medicare — Is the Patient: Month Day Year
a)Entitled to Benefits Under Medicare Hospital Insurance (Part A)
Ye s
No Effective ______/______/______
b)Entitled to Benefits Under Medicare Medical Insurance (Part B)
Ye s
No Effective ______/______/______
c)Entitled to Benefits Under Medicare due to a disability
Ye s
No Effective ______/______/______
Patient's Medicare Identification No. (From Medicare ID Card)____________________________
I certify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named
above. Authorization is hereby given to any Hospital, Physician, Dentist, Provider, Insurance Carrier or other entity to give
Blue Cross and Blue Shield of Texas, Inc., upon request, any medical information which the Plans in their judgment deem
necessary to the adjudication of this claim.
_____________________________________ _________________ __________________________
Signature of Insured Date Daytime Telephone Number
Itemized Bill(s) for Covered Services and Supplies must be attached
(See Instructions on Reverse Side)
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, 1081.000-901
an Independent Licensee of the Blue Cross and Blue Shield Association
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®®
Claim Form
to Pay
Insured/Subscriber
Type of treatment received:
Check only one type and attach itemized statements.
Please use a separate claim form for each different type
of treatment.
*Please note: Preventive care includes immunizations,
routine well baby care, routine physical examinations,
vision and hearing exams.
Blue Cross Blue Shield Association Medical Claim Form 1
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