Important: DO NOT le this form if your Provider of Service is submitting
these charges to Blue Cross and Blue Shield of Texas.
Please complete every item on claim form.
This completed form, together with the itemized bills, should be submitted to:
Blue Cross and Blue Shield of Texas
P.O. Box 660044
Dallas, Texas 75266-0044
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 730526.0915
to Pay Insured/Subscriber
name, address and
Please show the insured/subscriber’s name exactly as it appears on the Blue Cross and Blue Shield of Texas
identication card and specify the current address including the ZIP code. Check appropriate box indicating the
insured/subscriber’s employment status. If retired, give date of retirement.
Make sure the group number and identication number are exactly as shown on the insured’s identication
card. List patient’s full name; no nicknames or initials. Check the appropriate blocks for the patient’s sex and
relationship to the insured. Ensure the patient’s correct date of birth is shown.
Type of treatment
Check only one treatment type (injury, illness, pregnancy or preventive care) and specify date of injury, date
of rst symptom, date of conception or date preventive care was received. You may attach multiple itemized
statements if they are for one type of treatment (example: illness only, preventive care only).
Diagnosis or symptoms
of illness or injury
Give diagnosis or a brief description of symptoms. If preventive care services were received, state the type of
care (routine physical, hearing exam, vision exam, immunization or diagnosis, etc.).
If illness or injury is in
any way work-related
Check appropriate box and enter name and address of employer.
If motor vehicle injury Check appropriate box.
Other insurance Please check appropriate box. If “yes,” complete the required information.
Please check appropriate box concerning Medicare eligibility. If “yes,” show effective date and give Medicare
Medicare Enrollees should include a copy(s) of the Medicare Explanation of Benets Form(s) (EOB) with their
itemized statements unless patient is actively employed and requires group coverage to pay primary.
date and daytime
Please sign and date this form and attach your physician’s itemized letterhead statement(s). The itemized
statement(s) should contain all the information shown in the following example:
Example of Itemized Bill — Please remember to attach the original bill(s) to the claim form and make a copy
for your records. Itemized bills cannot be returned.
Dayton Penridge, M.D.
101 Fourth Street
(78659) Chest pain, other
or Professional Services Rendered To:
Virginia E. Warowes
9120 Excision of Cyst
9083 Biopsy, breast w/Ultrasound
3/6/15 G0008 Flu Vaccine Administration $XXX
FOR OTHER THAN PRESCRIPTION
DRUG CARD HOLDERS: Bills for
Prescription Drugs must show the
name of each drug, the prescription
number, the quantity dispensed, the
date of purchase, and the amount
charged for each drug, If drug is
generic then the pharmacist must
also indicate on itemized bill.
Bills for Private Duty
Nursing Service must show
the professional status of the
nurse (R.N. — Registered
Nurse, L.V.N. — Licensed
Vocational Nurse), the nurse’s
license number, and must be
accompanied by a statement
from your physician indicating
medical necessity and daily
nurse’s progress notes.
Name of the person or
organization providing the
services or supplies.
Name of the patient
receiving the services
If you are submitting itemized bills
for a variety of services please use a
separate claim form for each different
type of treatment (one for illness,
another for an injury, etc.).
Please cross out those charges which
were included on a previous claim.
service or supply
Description of the
services or supplies