MEM BER APPLICATION FOR PAYM ENT CONSIDERATION
Alpha
Sign after
printing
STATE
BCBSM GROUP NUMBER
ZIP CODE
Numeric
Fill out online, print, sign and mail with original receipts to:
PATIENT
INFORMATION
THIS INFORMATION CAN BE TAKEN
FROM YOUR BCBSM I.D. CARD
]
NAME OF OTHER INSURANCE POLICY NUMBER
SUBSCRIBER'S FIRST NAME
SUBSCRIBER'S ALPHA/NUMERIC CONTRACT NUMBER
PATIENT'S FIRST NAME SEX
SUBSCRIBER'S LAST NAME
OTHER HEALTH
INSURANCE?
PHONE
SUBSCRIBER'S STREET ADDRESS
NO
MEMBER
INFORMATION
DISCHARGE DATE
YES
WAS THIS
WORK RELATED ?
MEDICARE HIB NUMBER
DATE OF INJ/ILL/LMP ADMISSION DATE
CITY
FM
NO NOYES
WASTHISRELATEDTO
AN AUTO ACCIDENT?
YES
DATE SUBSCRIBER'S SIGNATURE
To speed up our processing remember to:
If the patient has Medicare coverage, fill i n the Medicare number incl uding alpha characters. Be sure you include the Medicare
Summary Notice that was sent explai ning the charges paid or not paid by Medicare. This is not requi red f or dental, vision or
hearin g services.
Mail only original receipts including all pertinent information on provider's letterhead. Without this information your claim will be
returned to you. Cash register recei pts, cancelled checks, money orders, and personal itemizations cannot be used i n benefi t
payment consideratio n.
Separate claim form s are necessary for different patients. You will also need and use another claim form for each of the different
programs (medical, dental, visio n, hearing).
Blue Cross Blue Shield of Michigan i s a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association
I certify that the above information is true and the enclosed materi al is correct and unaltered and the expenses were incurred by
the p atient. I unders tand all material submitted becomes the prop erty of Blue Cross Blue Shield of Michigan and will not be
retur ned. I realize false rec eipt or fraudulen t alterations of th ese materials will r esult in civ il or criminal prosecution. I au thorize
the release of any information necessary to process or review this claim.
W F 10282 APR 08
Make copies of the original receipts for your files before submitting the original. All materials submitted will be retained for our
fi l es and cannot be returned to y ou.
YOUR RIGHT TO CONFIDENTIALITY: We will not r elease any information about you except:
(1) When you ask us to in writing or (2) When rel ease (to another i nsurance company for
example) is necessary to pr ocess or review a claim. We wil l tell you which information we rel ease
to whom, if you request it.
If the pati ent has other health insurance that has processed the service, be sure you i nclude the Explanati on of Benefit statement
that was sent explaining the charges paid or not paid.
BLUE CROSS BLUE SHIELD OF MICHI GAN
P.O. BOX 49
DETROIT, MI 48231-0049
Dental
