Non-Medicare Blue Preferred PPO
SM
Member Flu Shot Reimbursement
Form
Fill out (online or by hand), print, sign and mail this form with original receipts to:
Blue Cross Blue Shield of Michigan
Imaging and Support Services
Member Claims MC 0010
600 E. Lafayette Blvd.
Detroit, MI 48226-2998
Patient's Enrollee ID
The enrollee or member ID can be found on your Blue Cross ID card
Alpha
Numeric
Group number
Member information
Subscriber's last name
Subscriber's first name
Subscriber's street address
City
State ZIP code
Patient's date of birth
Sex
M
F
To process your request, please remember to:
•
Complete
one form for each
enrollee.
•
Mail only original clear itemized
bill(s) on your provider's letterhead that include the following:
- Your flu shot provider's logo, address, and phone number (for example - from a doctor, pharmacy
or local health department)
- Date of service
- Amount paid
- Vaccine name or description
•
Keep copies of your original receipts for your files. We can’t return originals to you.
I certify the above information is true, the enclosed material is correct and unaltered, and the expenses
were incurred
by the enrollee listed above. False receipts or altering of this information will result in civil
or criminal prosecution. I authorize the release of any information as described below
.
Enrollee’s signature Date Phone
We value your privacy: We wo
n't release any information about you unless you ask us to in writing
or we
must do so to process or review your
claim (sharing with another insurance company, for
example).We'll tell you which information we released and to whom, if you request it.
WF 16935 NOV 17
Patient's information
Patient's last name Patient's first name
