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Administered by:
Month
Day
Year
Type of coverage:
Medical
Dental
Vision
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
7. Payment for the attached bills should be made to: (CHECK ONE)
8.
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.
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