Fillable Please fully complete the form, print clearly (Blue Cross Blue Shield of Michigan)

Fill Online, Printable, Fillable, Blank Please fully complete the form, print clearly (Blue Cross Blue Shield of Michigan) Form

Use Fill to complete blank online BLUE CROSS BLUE SHIELD OF MICHIGAN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Please fully complete the form, print clearly (Blue Cross Blue Shield of Michigan)

On average this form takes 6 minutes to complete

The Please fully complete the form, print clearly (Blue Cross Blue Shield of Michigan) form is 1 page long and contains:

  • 0 signatures
  • 3 check-boxes
  • 23 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Blue Cross Blue Shield of Michigan forms online.

BROWSE BLUE CROSS BLUE SHIELD OF MICHIGAN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Member Reimbursement
Usually, we pay your health care providers for you without you having to do anything. But, sometimes
you have to pay the doctor or hospital yourself. This form is how you ask us to reimburse you.
Please fully complete the form, print clearly
Section 1 — Member information
From your
Blue Cross
Blue Shield of
Michigan member
ID card
Subscriber's alpha-numeric contract number
Blue Cross
group number
Alpha:
Numeric:
Subscribers last name
Subscribers first name
Subscriber’s street address
State
ZIP
Section 2
— Patient information
Patient’s first name
Sex
Medicare HIB / MBI number
M F
Patient’s
date of birth
Date of
illness or injury
Admission
date
Discharge
date
Was this related to: Check box that applies
☐
☐
Auto Acc
ident Work Related
Metabolic Diseases & Foods
Accidental Dental
☐
This was related to:
Other:
__________________________________
Other health
insurance
Yes No
Section 3 — Other insurance information
Name of other insurance
Policy number
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.
Sign after printing.
X
Signature
Date
Clear Form
Member Reimbursement
How to submit your reimbursement form
Questions
Fax to : 1-844-318-5146
Or
Mail to:
Blue Cross Blue Shield of Michigan
Member Reimbursement
– Mail Code: 0010
600 E. Lafayette Blvd.
Detroit, MI 48226
Keep a copy of all documents you send us. Allow 30 days for processing.
Call Customer Service at the
number on the back of your
Blue Cross member ID card.
DF 16006 JUL 16 2018
Send the provider’s statement and a copy of your paid receipt (if paid using personal check, please
provide copies of the front and back of the check) with this form by U.S. mail or fax. Make sure the
statement shows the patient’s name, date of service, diagnosis code (a code that describes the
condition), procedure code (a code that describes what service your provider is billing for), the amount
charged for each service performed and proof of payment. If you have questions, please call Customer
Service.
To speed up our processing remember to:
• Fill out a separate form for each claim.
• 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, canceled checks, money orders and
personal itemizations cannot be used in benefit payment consideration.
• Make copies of the original receipts for your files before sending us the original. We will keep all
materials in our files and they cannot be returned to you.
• 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.
If another health care plan has already paid a portion of the service, attach a copy of the explanation of
benefits you received from that other plan.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Please fully complete the form, print clearly (Blue Cross Blue Shield of Michigan)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 10 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document