SUBSCRIBER INFORMATION (person in whose name coverage is held)
Identification Number (including prefix) SUBSCRIBER LAST NAME FIRST NAME
Address: Number and Street City State Zip Code
Employee’s Name
MEMBER INFORMATION (Use a separate form for each member.)
Member’s Last Name First Name Middle Initial Date of Birth Mo. / Day / Year
/ /
Mailing Address (if different from subscriber’s)
Address: Number and Street City State Zip Code
Gender Claimant is (check one):
q Male q Subscriber (coverage holder) q Child (age 18 and younger) q Student (age 18 and older)
q Female q Spouse q Handicapped Dependent (age 19 or older) q Stepchild q Other (specify) __________
WHEN TO SUBMIT THIS FORM:
• After the course is completed
• Please check your certificate of coverage for a complete listing of coverage benefits
TOTAL NUMBER OF RECEIPT COPIES ATTACHED: _____________ TOTAL AMOUNT OF RECEIPTS SUBMITTED: $ _________________
CERTIFICATION AND AUTHORIZATION (This form must be signed and dated below.)
I authorize the release of any information to Blue Cross and Blue Shield of Massachusetts, Inc., about my program. I certify that the information provided in support of this submission
is complete and correct and that I have not previously submitted for these services.
Subscriber’s/Member’s Signature:_________________________________________Date:__________________
Please mail this form (including copies of paid receipts to): BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, LOCAL CLAIMS DEPARTMENT
PO BOX 986030, BOSTON, MA 02298
Childbirth Classes Reimbursement Form
(Please print all information clearly.)
DO NOT WRITE IN THIS SPACE
OFFICE USE ONLY
TAKE A
CHILDBIRTH
CLASS
CLASS/PROGRAM INFORMATION REQUIRED
(Attach 8.5" x 11" photocopies of paid childbirth classes program receipts)
Name and Address of Class/Program Amount Charged
Happier Beginnings Start Here
Receive reimbursements when you take advantage
of childbirth education courses.
Get ready for the experience of childbirth by taking a
childbirth education course. They’ll help you:
• Prepare for delivery
• Learn how to make the birthing process more comfortable
• Make decisions about your birthing plan
• Socialize with other future parents
• Ask questions
We’ll Reimburse You
If you’re eligible for this benefit, we’ll reimburse you up to $90
for first-time-mother courses, and $45 for refresher courses.
Important Tips
• Check with your doctor to see if the hospital you’ve chosen
for delivery offers childbirth classes
• If attending a class elsewhere, look for an instructor certified
in childbirth or Lamaze
• Consider an instructor who is a registered nurse and experienced
in labor and delivery
Questions?
If you have any questions, call the Member
Service number on the front of your ID card.
