Subscriber'S Statement Of Claim - Blue Shield Of California
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1Subscriber’s Statement of Claim
This form is to be used ONLY when the Provider of Service does not submit your claim directly to Blue Shield.
Check with the Provider to be sure no claim has been submitted.
Duplicate claims will not only be rejected, but may delay payment of the original claim.
Important instructions
• Use a separate form
Exceptions
A. Each member of the family
• Primary Medicare coverage
B. Each different provider of service
A. Submit claim to Medicare first
C. Each itemized bill
B. Complete boxes 1 and 4 only
• Print or type
C. Attach your Explanation of Medicare Benefits
form and a copy of itemized services to this
• Fill in all items completely
claim and send all to Blue Shield
• Sign your name in the space provided
• F oreign claims – any services rendered outside of
Failure to comply with these instructions may result
the United States or its territories must include the U.S.
in your claim being delayed or returned to you
currency exchange rate or value and the translation
for all billed services
1
Subscriber name
Subscriber number
Group number
(last, first, MI)
Mail address
Is address new?
(street, city, state, ZIP)
Yes
No
c
c
2
Name of patient
Date of birth
(last, first, MI)
(month, day, year)
Relationship to subscriber
Patient's gender
Self
Spouse
Child
Domestic partner
Male
Female
c
c
c
c
c
c
Describe briefly patient's illness or injury, and, if injury, how it occurred
Patient was treated for
Date of injury; onset of illness or pregnancy
Is patient retired?
If Yes, effective date
Yes
No
Injury
Illness
Pregnancy
c
c
c
c
c
3
Does patient have other health coverage?
If Yes, policy ID No.
Name of insuring company
Effective date
Yes
No
c
c
Address of insuring company
Type of plan
Group
Individual
c
c
Name of policy holder
Gender
Date of birth
Name of employer
Male
c
Female
c
4
Was condition related to employment?
Does patient have Medicare?
If Yes, Part A effective date
If Yes, Part B effective date
Yes
No
Yes
No
c
c
c
c
Subscriber signature
For your protection, California law requires the following to appear on this form:
Important notice: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may
be subject to fines and confinement in a state prison.
I certify that the foregoing information is accurate and complete, and authorize the release of any medical information necessary
to process this claim.
X
_______________________________________________________________________ Date: __________________
Send this claim to: Blue Shield of California Life and Health Insurance Company, P.O. Box 272610, Chico, CA 95927-2610
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