N-12-420
80632
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0314
BlueCard Worldwide
®
International Claim Form
Florida’s Blue Cross and Blue Shield Plan
Please see the instructions on the reverse side of this form before completing. Please type or print.
Send completed form to: BlueCard Worldwide Service Center or claims@bluecardworldwide.com
P.O. Box 261630
Miami, FL 33126 USA
1. Patient Information — 1A. Alpha prex Identication number Copy this from your Florida Blue identication card.
1B. Patient’s name (First, middle initial, last) 1C. Patient’s date of birth
MM/DD/YYYY
_______ / _______ / _______
1D. Patient’s sex
Male Female
1E. Name of subscriber (First, middle initial, last) 1F. Subscriber’s date of birth
MM/DD/YYYY
_______ / _______ / _______
1G. Patient’s relationship to
subscriber
Self Spouse Child
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? Yes No
If yes, complete 2A through 2K below.
2A. Name and address of other insurance company
2B. Type of policy
Family Individual
2C. Effective date
MM/DD/YYYY
_______ / _______ / _______
2D. Termination date
MM/DD/YYYY
_______ / _______ / _______
2E. Policy or identication number of
other coverage
2F. Type of coverage
Hospital: Yes No
Medical:
Yes No Mental illness: Yes No
2G. Name of subscriber 2H. Date of birth
MM/DD/YYYY
_______ / _______ / _______
2I. Employer of subscriber 2J. Employment status
Active employee Retired employee
2K. 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 provider
making charge
______________________________
_________________________ ___________________________
_______________________
_____________________
_____________________________________________________
_________________________ ___________________________ _____________________
______________________________
_________________________ ___________________________
_______________________
_____________________
______________________________
4B. Type of provider
_________________________
4C. Description of service
___________________________
4D. Dates of service or
purchase
_______________________
4E. Alpha prex
_____________________
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 benets due herein to be made to the following provider of services, if such direct payment is deemed appropriate by
Florida Blue:
Name of provider _______________________________________ Signature of subscriber or spouse ___________________________________Date ________________
6. Signature — I certify the above is complete and correct and that I am claiming benets 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 Florida Blue 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 Florida Blue 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 Florida Blue Plan’s Notice of
Privacy Practices.
Signature of subscriber or patient _______________________________________________________________________________________Date __________________
