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 expedite processing remember to:
If the patient has Medicare coverage, fill in the Medicare number including alpha characters.
Mail only original receipts including all pertinent information on provider's letterhead. Without this information your claim will
be returned to you. Cash register receipts, cancelled checks, money orders, and personal itemizations cannot be used in benefit
payment consideration.
Use a separate Member Application for Payment Consideration form for each patient.
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 10282 APR 08
Make copies of the original receipts for your files before submitting the original. All materi als submitted will be retained for our
files and cannot be r eturned 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 the service, be sure you include the Explanation of Benefit statement
that was sent explaining the charges paid o r not paid.
BLUE CROSS BLUE SHIELD OF MICHIGAN
P. O. BOX 49
DETROIT, MI 48231-0049
Dental
BIRTH DATE
SUBSCRIBER BIRTH DATE
SUBSCRIBER NAME
