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HEALTH CARE PLAN

MEMBER CLAIM FORM


Found on your Premera Blue Cross ID card 1. Premera Blue Cross ID number: 2. Patients name: Last Relationship to employee: Is patient full time student? If different than above: 3. Employees name: (Print) Last Employees address: City 4. Does the patient have other health coverage? Name of other insurance company: Member ID: No Yes If Yes, provide: Street (P.O. Box) First No Prefix: MSJ First Patients birthdate: Yes, provide school: MSQ

Administered by:

Employees E-mail name:

Group #1000010 M.I.

Month

Day

Year

M.I. Telephone number ( ) - State ZIP

Type of coverage:

Medical

Dental

Vision

Effective date of coverage: Month Day Year

Termination date of coverage: Month Day Year

If patient is a child, give parent(s) birthdate(s): Mother: Month Day Year Father: Month Day Year 5. Is treatment for injury? No Yes Briefly describe how injury occurred/diagnosis: Date of Injury: Month Day Year

Where did injury occur? Work Home School Other 6. International claims Use a separate line to list each type of service or provider and attach itemized bills for all services.
Name of Provider Making Charge Type of Provider Country Services Rendered Description of Service Dates of Service or Purchase Charges

The member

The provider listed on the bill(s)

7. Payment for the attached bills should be made to: (CHECK ONE)
8.

NOTE: In some circumstances, payment will always be made to the member.

Please Note: In submitting this form to Premera Blue Cross or having it submitted for you, you authorize the service provider named in the attached bills to release medical and other information to Premera Blue Cross as needed to verify Plan coverage. SIGNATURE DATE _________________________________

Please Note: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

PROCEDURE FOR FILING A CLAIM 1. 2. 3. Complete Sections 18. If you submitted a request for benefits to another plan, attach a copy of the bills you submitted to the other plan and explanation of benefits you received from the other plan. ITEMIZED BILLS MUST INCLUDE: Dates of service, diagnosis code, CPT (medical) or ADA (dental) procedures codes, tooth number and surface, patient name, provider name, provider tax identification or Social Security number, provider address and telephone number. This form is not valid unless signed. Send the completed benefits request and the bills to:

4. 5.

Premera Blue Cross P. O. Box 91059 Seattle, WA 98111-9159

Customer Service: 1-800-676-1411

Please Note: Premera Blue Cross will not pay a bill submitted more than 12 months after the date of service.

011943 (02-2010)

Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association

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