MEMBER APPLICATION FOR PAYMENT 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 NO
YES
WAS THIS RELATED TO
AN AUTO ACCIDENT?
YES
DATE SUBSCRIBER'S SIGNATURE
To speed up our processing remember to:
If the patient has Medicare coverage, fill in the Medicare number including alpha characters. Be sure you include the Medicare
Summary Notice that was sent explaining the charges paid or not paid by Medicare. This is not required for dental, vision or
hearing services.
Mail only original receipts including all pertinent information on provider's letterhead. Without this i nformation your claim will
be returned to you. Cash register receipts, cancelled checks, money orders, and personal itemizations cannot be used in benefit
payment consideration.
Separate claim forms are necessary for different patients. You will also need and use another claim form for each of the different
programs (medical, dental, vision, hearing).
Blue Cross Blue Shield of Michigan is 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 material is correct and unaltered and the expenses were incurred by
the patient. I understand all material submitted becomes the property of Blue Cross Blue Shield of Michigan and will not be
returned. I realize false receipt or fraudulent alterations of these materials will result in civil or criminal prosecution. I authorize the
release of any information necessary to process or review this claim.
WF 3861 NOV 11
Make copies of the original receipts for your files before submitting the original. All materials submitted will be retained for our
files and cannot be returned to you.
YOUR RIGHT TO CONFIDENTIALITY: We will not release any information about you except:
(1) When you ask us to in writing or (2) When release (to another insurance company for
example) is necessary to process or review a claim. We will tell you which information we release
to whom, if you request it.
If the patient has other health insurance that has processed t he service, be sure you include the Explanation of Benefit stat ement
that was sent explai ning the charges paid or not paid.
Medical, Vision and
Hearing Benefit
PATIENT'S DATE OF BIRTH
Blue Cross Blue Shield of Michigan
Member Claims MC B321
600 E. Lafayette Blvd.
Detroit, MI 48226-2998
