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Short Term Health Insurance Claim Form

Blue Shield of California Life & Health Insurance Company

P.O. Box 1557, Minneapolis, MN 55440 1-866-510-8778

Please complete the entire enrollment form. This form cannot be processed if information is incomplete.

Please print all sections in black ink.

Attach itemized bills or prescription receipts.

Sign the Authorization below.

Send the completed form directly to Blue Shield Life at the address shown above.

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.

Section 1

Name of the insured

Telephone no.

Social security no.

Policy no.

Mail address

City

State

Zip code

Name of patient

Birthdate (mo./day/yr.)

Relationship

Have you, your spouse, or covered children been insured under another health plan during the twelve months prior to the

effective date of this policy?

Yes

If “Yes,” complete the following: (if there was more than one insurance carrier,

please attach a separate page with the following information about each plan)

Policyholder name

Policy or ID#

Group number

Effective/Terms dates

Name of insurance company

Address of claims office

Telephone no. of claims office

Employer or government service name

Employer or government service address

Telephone no.

Section 2

Describe condition responsible for expenses: (if injury, provide details of injury, including date)

Expenses were the result of:

Date treatment first occurred

Date symptoms were first noticed

(mo./day/yr.)

Injury

Illness

Pregnancy

Physician’s name

Physician’s complete address

Telephone no.

Section 3

Please sign this assignment of benefits if you wish payment to be made to any of the health care providers listed below.

I authorize payment of benefits to the provider(s) indicated below:

Insured or authorized person:

Date:

List below all physicians and other health care providers seen for this condition:

Name

Address

Telephone no.

Dates seen

Assignment?

Yes

Authorization to obtain information

I authorize these persons having any records or knowledge of me or my health: physician, medical or health care provider, hospital, clinic, pharmacy or

other medical or medically related facility, insurance company, employer or plan administrator, government agency, organization or entity administering

a benefit program, educational, vocational or rehabilitation organization or program, to give this information: all medical information on me, including

medical history, diagnosis, prognosis and treatment of any physical or mental condition, to Blue Shield Life. I understand that Blue Shield Life will use the

information to determine my eligibility or entitlement for insurance benefits. I understand I have right of access and correction with respect to all personal

information provided under this authorization. Blue Shield Life may release information about me to a reinsurer, a plan administrator, or any person

performing business for legal services or Blue Shield Life in connection with my claim. I understand and agree that this authorization shall remain in force

throughout the duration of my claim for benefits with Blue Shield Life. A photocopy of this authorization is as valid as the original.

Insured/Patient

(print name)

Signature

Date