Form C-14764 - International Claim Form - Blue Shield Of California printable pdf download

International Claim Form

Send completed form to:

Blue Shield of California/Blue Shield of California Life & Health Insurance Company

International Claims

P. O. Box 272550

Chico, CA 95927-2550 USA

Please see the instructions on the reverse side of this form before completing. Please type or print.

1. Member Information – 1A. Alpha prefix

Identification number

(Copy this from your Blue Shield ID Card)

| _ | _ | _

| _ | _ | _ | _ | _ | _ | _ | _ | _

1B. Patient’s name

1C. Patient’s date of birth

1D. Patient’s gender

(First, Middle Initial, Last)

❑

MM/DD/YY

Male

Female

1E. Name of subscriber

1F. Subscriber’s date of birth

1G. Patient’s relationship to

subscriber

(First, Middle Initial, Last)

❑

Self

Spouse

Child

Domestic Partner

MM/DD/YY

Subscriber’s current mailing address

(Street, City, State and Country or ZIP Code)

2. Other Health Insurance – Is the patient covered under other health insurance including Medicare A or B?

❑ Yes

❑ No

If yes, complete 2A through 2K below.

2A. Name and address of insurance company

2B. Type of contract

2C. Effective date

2D. Termination date

2E. Policy or identification number of other coverage

❑

Group

❑

Individual

MM/DD/YY

2F. Type of Coverage

2G. Name of contract holder

2H.Date of birth

Medical:

❑

Yes

❑

MM/DD/YY

2J. Employment status

2I. Employer of contract holder

❑

Active employee

Retired employee

2K. If patient is covered under Medicare, complete the following: Medicare Part A: ❑ Yes

❑ No

Medicare Part B: ❑ Yes

❑ No

Effective date ________________

3. Diagnosis – 3A. Describe illness, injury, or symptoms requiring treatment

3B. Was patient’s condition due to a work-

related accident or condition?

❑ Yes ❑ No

3C. Complete for care related to accidental injuries

Date of accident ________________________

Location:

❑

Home while residing outside the United States

❑

Auto

❑

Other ____________________

Time of accident ________________________

If the accident was caused by someone else, attach a statement describing the accident.

4. Charges – Please list below those charges that you are claiming for benefits. Use a separate line for each type of service or

provider and attach itemized bill for all services claimed.

4A. Type of provider

4B. Name of provider

4C. Description of service or supply

4D. Dates of service or purchase 4E. Charges

___________________

____________________

_________________________________

___________________________ __________

___________________

____________________

_________________________________

___________________________ __________

___________________

____________________

_________________________________

___________________________ __________

___________________

____________________

_________________________________

___________________________ __________

___________________

____________________

_________________________________

___________________________ __________

5. Signature – I certify the above is complete and accurate to the best of my knowledge and that I am claiming benefits only for charges

incurred by the patient named above.

Authorization is hereby given to any provider of service, that participated in any way in the patient’s care, to release to Blue Shield of

California, Blue Shield of California Life & Health Insurance Company, and its business associates in any country any medical or other

personal information that they deem necessary to provide service or adjudicate this claim, recognizing that applicable law concerning

personal information may differ among countries. Authorization is also given to Blue Shield of California, Blue Shield of California Life &

Health Insurance Company, and its business associates in any country to collect, use or release any medical or other personal information

that they deem necessary to provide service or adjudicate a claim.

Signature of subscriber or patient ____________________________________________________________

Date __________________

6. Authorization for Assignment of Benefits

I, the undersigned, authorize and request Blue Shield of California or Blue Shield of California Life & Health Insurance Company to make

payment for benefits due herein to:

Signature of subscriber or patient ____________________________________________________________

Date __________________

C-14764 (7/05)

Form C-14764 - International Claim Form - Blue Shield Of California

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