Claim Form
to Pay Insured/Subscriber
P.O. Box 660044 • Dallas, Texas 75266-0044
Each item on this form needs to be completed.
Instructions for completion are listed on the reverse side.
Insured/Subscriber Name (Last, First, Middle Initial)
Mailing Address
City and State ZIP Code
Insured Employed? Date of Retirement:
Month Day Year
£ Yes £ No £ Retired __________ /__________ /_____________
Please print or type.
Type of treatment received:
Check only one type and attach itemized statements. Please use
a separate claim form for each different type of treatment.
Please note: Preventive care includes immunizations, routine
well baby care, routine physical examinations, vision and
hearing exams.
Month Day Year
£ Injury — Date of accident: __________ /__________ /_____________
£ Illness — Date of rst symptom: __________ /__________ /_____________
£ Pregnancy — Date of conception: __________ /__________ /_____________
£ Preventive — Date of service: __________ /__________ /_____________
Describe: Diagnosis, symptoms of illness or injury or explain preventive or routine care received.
Group Number
Insured/Subscriber Identication Number (from ID card)
Patient’s Full Name (Last, First, Middle)
Patient’s Sex Patient’s Date of Birth Month Day Year
__________ /__________ /_____________
Patient’s Relationship to Insured
£ Self £ Spouse £ Child £ Other (explain) _______________________________________
Was illness or injury work connected? £ Yes £ No
Name and address of employer
If injury, was a motor vehicle involved? £ Yes £ No
Is patient covered under any other health benets plan (besides Medicaid, Medicare or CHAMPUS)? £ Yes £ No
Insurance Co. _____________________________________________________________________
Address __________________________________________________________________________
Employer _________________________________________________________________________
Insured name ____________________________________________________________________
Policy # ___________________________________________________________________________
Month Day Year
Effective date of coverage ___________ /___________ /______________
Sex of Insured
£ Male £ Female
Date of birth of insured ___________ /___________ /______________
Relationship to patient _________________________________________________________
If the other coverage is primary, attach the other insurance companys Explanation of Benets.
I certify the above is complete and correct and that I am claiming benets only for charges incurred by the patient named above.
Authorization is hereby given to any Hospital, Physician, Dentist, Provider, Insurance Carrier or other entity to give Blue Cross and
Blue Shield of Texas, upon request, any medical information which the Plans in their judgment deem necessary to the adjudication of this
claim. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to
nes and connement in state prison.
Signature of Insured
Date Daytime telephone number
Medicare — Is the patient:
a) Entitled to benets under Medicare insurance (Part A)?
b) Entitled to benets under Medicare insurance (Part B)?
c) Entitled to benets under Medicare due to a disability?
Month Day Year
£ Yes £ No Effective ___________ /___________ /______________
£ Yes £ No Effective ___________ /___________ /______________
£ Yes £ No Effective ___________ /___________ /______________
Patient’s Medicare Identication Number. (From Medicare ID card) ___________________________________________________________________________________________________
Total amount for ALL covered services and supplies received. $
Itemized Bill(s) for covered services and supplies must be attached. (See Instructions on reverse side.)
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
Claim Form
to Pay Insured/Subscriber
name, address and
employment status
Please show the insured/subscribers name exactly as it appears on the Blue Cross and Blue Shield of Texas
identication card and specify the current address including the ZIP code. Check appropriate box indicating the
insured/subscribers employment status. If retired, give date of retirement.
Patient information
Make sure the group number and identication number are exactly as shown on the insured’s identication
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.
Medicare information
Please check appropriate box concerning Medicare eligibility. If “yes,” show effective date and give Medicare
identication number.
Medicare Enrollees should include a copy(s) of the Medicare Explanation of Benets Form(s) (EOB) with their
itemized statements unless patient is actively employed and requires group coverage to pay primary.
Insured’s signature,
date and daytime
telephone number
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
Healthville, U.S.A.
Diagnosis Code:
(78659) Chest pain, other
or Professional Services Rendered To:
Virginia E. Warowes
G0206 Mammogram
9120 Excision of Cyst
9083 Biopsy, breast w/Ultrasound
90659 Flu
3/6/15 G0008 Flu Vaccine Administration $XXX
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 nurses
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
or supplies
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.
Date each
service or supply
was provided
Description of the
services or supplies
Charge for
each service
or supply