Blue Cross Blue Shield International Medical Claim Form
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1. Patient Information— 1A. Alpha prefix Identification number Copy this from your Blue Cross Blue Shield identification card.
1B. Patient’s name(First, middle initial, last)1C. Patient’s date of birth1D. Patient’s sex
1E. Name of subscriber (First, middle initial, last)1F. Subscriber’s date of birth 1G. Patient’s relationship
1H. Subscriber’s 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 YesNo
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
FamilyIndividualMM/DD/YYYYMM/DD/YYYYof other coverage
2F. Type of coverage Hospital: Yes No2G. Name of subscriber 2H. Date of birth
Medical: YesNo Mental illness: YesNoMM/DD/YYYY
2I. Employer of subscriber 2J. Employment status
Active employeeRetired employee
If patient is covered under Medicare, complete the following: Medicare Part A:
Medicare Part B:
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 conditionYesNo
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 provider4C. Description of service4D. Dates of service 4E. Charges
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