Fillable Member Claim Form P LEASE TYPE or PRINT (Motion Picture Industry Pension and Health Plans)

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Member Claim Form P LEASE TYPE or PRINT (Motion Picture Industry Pension and Health Plans)

On average this form takes 16 minutes to complete

The Member Claim Form P LEASE TYPE or PRINT (Motion Picture Industry Pension and Health Plans) form is 1 page long and contains:

  • 0 signatures
  • 12 check-boxes
  • 59 other fields

Country of origin: US
File type: PDF

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DATE OF SERVICE
(Mo/Day/Yr)
PROVIDER OF SERVICE
(Name of Doctor, Lab, Amb. Co., etc.)
SERVICE RENDERED
(Office Visit, X-ray, etc.)
ILLNESS OR DIAGNOSIS TOTAL
GRAND
T
O
T
AL
NAME Last First Middle Initial MEMBER ID GROUP NUMBER
BIRTHDATE SEX RELATION TO SUBSCRIBER NAME Last First Middle Initial
D
OES THE PATIENT HAVE OTHER HEALTH INSURANCE COVERAGE? ADDRESS
N
AME OF OTHER HEALTH INSURANCE COMPANY CITY STATE ZIP CODE
POLICY NUMBER HOME PHONE NO. WORK PHONE NO.
MEDICAL INFORMATION
PATIENT INFORMATION SUBSCRIBER INFORMATION (on Anthem Blue Cross Card)
Member Claim Form
P
lease use a separate claim form for each patient. Your cooperation in completing all items on the claim form and attaching all required
documentation will help expedite quick and accurate processing.
P
LEASE TYPE or PRINT • SEE REVERSE SIDE FOR COMPLETE INSTRUCTIONS
MF
() ()
Self Spouse Son Daughter
Yes No
HEALTH CARE SERVICES: Use this section to report any COVERED health service that has not already been reported to this Anthem Blue Cross
Plan by the provider of service (the physician, clinical, ambulance company, private duty nurse, etc.) Attach itemized bill or photocopy. Please be
sure that duplicate bills are not submitted.
Was this medical expense the result of an accident? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO
Was this condition or injury job related? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO
Have you filed for Workers’ Compensation?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO
On what day did this injury or accident occur?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Month:____ Day:____ Year:____
Have you been treated for the same condition within the last 24 months? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO
If yes, indicate date you were last treated: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Month:____ Day:____ Year:____
If th
e bill is from a Licensed Clinical Social Worker; Marriage, Family and Child Counselor; Audiologist; or Occupational,
Physical, or Speech Therapist; what is the name of the physician who ordered the service?
Dr. ______________________________________________________________________________________
I certify that the information on this Member Claim Form is true and correct to the best of my knowledge. I authorize the release of any medical
information necessary to process this claim.
X
SIGNATURE OF SUBSCRIBER DATE
Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association.
® ANTHEM is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association.
anthem.com/ca IU2013 Effective 6/08
$
H
OW TO USE THIS FORM
D
ear Member:
U
sually, all providers of health care will bill us for services to you and your enrolled dependents. This is the preferred procedure. You are not
bothered with claim forms and we often need more details than are ordinarily provided on bills to patients.
S
ometimes, a physician may not bill us, or an ambulance company, for example, may send the bill directly to you. In either instance, we have
no way of knowing about your claim. This Member Claim Form was developed to notify us of any covered health service for which we have not
already been billed. Please read the following instructions about how to report Health Care Services.
W
e are happy to serve you.
PATIENT INFORMATION SUBSCRIBER INFORMATION (on Anthem Blue Cross Card)
Use this section to identify the patient and subscriber. Some of this information may be found on your Anthem Blue Cross card.
MEDICAL INFORMATION
HEALTH CARE SERVICES: Use this section to report any COVERED health service which has not already been reported to this Anthem Blue Cross
Plan by the provider of service (the physician, clinical, ambulance company, private duty nurse, etc.) Attach itemized bill or photocopy. Please be
sure that duplicate bills are not submitted.
D
ATE OF SERVICE PROVIDER OF SERVICE SERVICE RENDERED
ILLNESS OR DIAGNOSIS TOTAL
(Mo/Day/Yr) (Name of Doctor, Lab, Amb. Co., etc.) (Office Visit, X-ray, etc.)
5/9/08 John Wang, M.D. Office Visit Bronchitis $35.00
5/9/08 Pat Fogarty, M.D. X-ray Strain $57.00
GRAND
TOTAL
$92.00
THE FOLLOWING INFORMATION MUST ALSO BE INCLUDED ON BILLS FOR THESE ITEMS:
REGISTERED AND LICENSED VOCATIONAL NURSES:
•
Hours and dates of service
•
Location of service (residence or name of hospital)
•
Written documentation of physician’s referral (must include the state license number, plan of treatment and estimated duration
of treatments)
PROSTHETIC DEVICES, APPLIANCES OR DURABLE MEDICAL EQUIPMENT:
•
Doctor’s orders or prescription
•
Purchase price
AMBULANCE:
•
Pick-up and delivery points
•
Number of miles
BILLS MUST BE ITEMIZED:
C
ancelled checks, cash register receipts and non-itemized “balance due” statements cannot be processed. Each itemized bill must include:
•
Name and address of provider (doctor, hospital, laboratory, ambulance service, etc.)
•
N
am
e o
f pa
tient
•
Service provided
•
Date of service
•
Amount charged for each service
•
Diagnosis
MEMBER CLAIM FORM INSTRUCTIONS:
For services rendered in C
alifornia
, pl
ease send claims to P.O. Box 60007, Los Angeles, CA 90060
For
out-of-state claims, pl
ea
s
e co
nt
act Customer Service for the claims office address. Out-of-state claims must be sent to the Blue Plan
of the state in which services were rendered. For your convenience, the Customer Service number is listed on your Member ID card.
NOTE: If your coverage includes Prescription Drug benefits, call (800) 700-2533 for customer assistance.
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Member Claim Form P LEASE TYPE or PRINT (Motion Picture Industry Pension and Health Plans)

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Completed 18 May 2021

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