blueshieldca.com
Subscriber’s Statement of Claim
Send this claim to: Blue Shield of California, P.O. Box 272540, Chico, CA, 95927-2540.
Please note that this form is to be used only when the provider of service does not submit your claim directly
to Blue Shield. Duplicate claims will not only be rejected but may delay payment of the original claim. Please
check with the provider to be sure no claim has been submitted.
Important instructions
• Use a separate form for:
A. Each member of the family
B. Each different provider of service
C. Each itemized bill
• Print or type
• Fill in all items completely
• Sign your name in the space provided
Failure to comply with these instructions may result in your
claim being delayed or returned to you.
Exceptions:
• Primary Medicare coverage
A. Submit claim to Medicare first.
B. Complete boxes 1 and 4 only.
C. Attach your explanation of Medicare benefits form and a copy
of itemized services to this claim and send all to Blue Shield.
• Foreign claims
Any services rendered outside of the United States or its territories
must include the US currency exchange rate or value and the
translation for all billed services.
1
Subscriber name (Last, First, MI) Subscriber number Group number
Mail address City State ZIP Is address new?
c Yes c No
2
Patient’s name Date of birth (mo/day/yr) Gender
c Male
c Female
Relationship to subscriber
c Self c Spouse
c Child
Describe briefly patient’s illness or injury and, if injury, how it occured
Patient was treated for
c Injury c Illness c Pregnancy
Date of injury, onset of illness or pregnancy Is patient retired?
c Yes c No
If Yes, effective date
3
Does patient have other health
coverage? c Yes c No
If Yes, policy ID number Name of insuring company Effective date
Address of insuring company Type of plan
c Group c Individual
Name of policyholder Gender
c Male
c Female
Date of birth Name of employer
4
Was condition related to employment?
c Yes c No
Does patient have Medicare?
c Yes c No
If Yes, date of birth Part A effective date Part B effective date
Subscriber’s signature
I certify that the foregoing information is accurate and complete, and authorize the release of any medical information necessary to process this claim.
________________________________________________________________________________________ Date _______________
Blue Shield of California is an independent member of the Blue Shield Association CLM14850 -FF (12/21)
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