Home > Life > Medical Forms > Medical Claim Template > Blue Cross Blue Shield International Medical Claim Template

Blue Cross Blue Shield International Medical Claim Form


Blue Cross Blue Shield International Medical Claim Form
Blue Cross Blue Shield International Medical Claim Form
1. Patient Information 1A. Alpha prefix Identification number Copy this from your Blue Cross Blue Shield identification card.
1B. Patients name (First, middle initial, last) 1C. Patients date of birth 1D. Patients sex
MM/DD/YYYY Male Female
1E. Name of subscriber (First, middle initial, last) 1F. Subscribers date of birth 1G. Patients relationship
to subscriber
MM/DD/YYYY
Self
Spouse Child
1H. Subscribers current mailing address (Street, city, state, and country or ZIP code) 1I. Patient’s e-mail address
2. Other Health Insurance Is the patient covered under other health insurance, including Medicare A or B Yes No
If yes, complete 2A through 2K below.
2A. Name and address of other insuring company
2B. Type of policy 2C. Effective date 2D. Termination date 2E. Policy or identification number
Family Individual MM/DD/YYYY MM/DD/YYYY of other coverage
2F. Type of coverage Hospital: Yes No 2G. Name of subscriber 2H. Date of birth
Medical: Yes No Mental illness: Yes No MM/DD/YYYY
2I. Employer of subscriber 2J. Employment status
Active employee Retired employee
2
K.
If patient is covered under Medicare, complete the following: Medicare Part A:
Yes
No
Medicare Part B:
Yes
No
Effective date ________________ Effective date _________________
3. Diagnosis 3A. Describe illness, injury, or symptoms requiring treatment and onset date of symptoms or injury.
3B. Was patient’s treatment due to a work-related accident or condition Yes No
3C. Complete for care related to accidental injuries
Date of accident _____________________________________ Location: At home Auto Other ____________________________
Time of accident ____________________________________ If the accident was caused by someone else, attach a statement describing the accident.
4. Charges Use a separate line to list each type of service or provider and attach itemized bills for all services.
4A. Name and address of 4B. Type of provider 4C. Description of service 4D. Dates of service 4E. Charges
provider making charge
or purchase
.................................................................................................................................... .............................................................................. ............................................................................................................................... .......................................................................... .................................................
.................................................................................................................................... .............................................................................. ............................................................................................................................... .......................................................................... .................................................
.................................................................................................................................... .............................................................................. ............................................................................................................................... .......................................................................... .................................................
.................................................................................................................................... .............................................................................. ............................................................................................................................... .......................................................................... .................................................
5. Payee Select one of the following payment options:
5A. Make payment to subscriber; provider has been paid.
1. Currency Please check your preference for payment: Currency on itemized bill(s) U.S. dollars
2. Payment Method – Please select your preference for how to receive your payment: Check (Provide current telephone number) _____________________________
Bank Wire. If you want to receive a bank wire provide the following:
Subscriber name as it appears on bank account: _____________________________________________________ Bank name: _____________________________________________
Bank’s Physical Address: _____________________________________________________________________________________________________________________________________
Account # /IBAN: ________________________________________________________________________Routing # / ABA / BIC / SWIFT: _______________________________________
5B. Make payment to provider (hospital, doctor), if appropriate. Please complete and sign to authorize direct payment to provider.
I, the undersigned, authorize and request payment for benefits due herein to be made to the following provider of services, if such direct payment is deemed appropriate
by Blue Cross and Blue Shield:
Name of provider _______________________________________ Signature of subscriber or spouse ________________________________________________ Date _________________
6. Signature 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 provider of service, that participated in any way in the patient's care, to release to the subscriber's Blue Cross and Blue Shield Plan and its business
associates in any country any medical or other personal information that they deem necessary to provide service or adjudicate this claim, recognizing that applicable
law concerning personal information may differ among countries. Authorization is also given to the subscriber's Blue Cross and Blue Shield Plan and its business
associates in any country to collect, use or release any medical or other personal information that they deem necessary to provide service, adjudicate a claim or as
otherwise described in such Blue Cross and Blue Shield Plan’s Notice of Privacy Practices.
Signature of subscriber or patient _________________________________________________________________________________________________ Date _________________________
BlueCard Worldwide
®
International Claim Form
Please see the instructions on the reverse side of this form before completing. Please type or print.
Blue Cross and Blue Shield Plans are
independent licensees of the Blue
Cross and Blue Shield Association.
/ /
/ /
/ /
/ /
/ /
Send completed form to: BlueCard Worldwide Service Center or [email protected]
P.O. Box 261630
Miami, FL 33126 USA
Blue Cross Blue Shield International Medical Claim Form
Previous

1/2

Next