Form 00361 - Medical Claim Form - Anthem Blue Cross And Blue Shield (2009)
ADVERTISEMENT
1
2Medical Claim Form
Read instructions on reverse side.
Mail to:
Anthem Blue Cross and Blue Shield
P.O. Box 36550
Louisville, KY 40233
PART I CUSTOMER AND PATIENT INFORMATION (please print or type)
7. Patient’s name (first, middle, last)
11. If the patient is other than the customer, is the patient covered by
1. Customer’s name ____________________________________________
any other group medical policy (including Blue Cross and Blue
Address __________________________________________________
Shield)?
yes
no If yes:
8. Patient’s relation to customer
City __________________________State________ZIP ____________
Other policyholder’s name ______________________________
self
self
(male)
(female)
husband
Patient’s employer ____________________________________
New Address Phone (________) ____________________________
1
2
3
Other insurer ________________________________________
wife
son
daughter
2. Customer’s sex
male
female
4
5
6
Other insurer’s address ________________________________
3. Group name
other male
other female
____________________________________________________
dependent
dependent
7
8
4. Customer’s certificate or ID number
Patient’s certificate number ____________________________
N
9. Patient’s birthdate
Age
__________________________________________________________
Effective date of patient’s contract ________________________
/
/
If arrow appears
Blue Cross Plan code ________________________________________
on ID card, copy
(numbers found on ID card)
Customer’s birthdate
12. Was condition related to:
numbers exactly.
/
/
A. Employment
yes
no B. Accident
yes
no
5. Is the patient eligible for Medicare?
yes
no
Spouse’s birthdate
If yes, please read filing instructions on reverse side.
Date ______________________________________________
/
/
Medicare Health Insurance Claim No. ____________________________
13. Describe the illness, injury or symptom ____________________
6. I authorize release to Anthem of any information
10. Is patient a full-time student
______________________________________________________
19 years of age or older?
pertaining to this claim.
______________________________________________________
yes
no
______________________________________Date ________________
If yes, name of school:
Date symptom first appeared ______________________________
Patient’s signature (parent or guardian, if minor)
PART II PHYSICIAN OR PROVIDER INFORMATION (to be completed by physician or provider only)
14. Date symptom first appeared
15. Date patient first consulted you
16. Has patient ever had similar
17. Referring physician
for this condition
symptoms?
yes
no
18. Name and address of facility where service was rendered (other than home or office)
19. For services related to hospitalization
Admission date:
Discharge date:
20. Is patient totally disabled?
Dates of total disability:
21. Was outside lab work performed?
22. Was service related to routine physical?
yes
no
From
To
yes
no
Charge:
yes
no
23. Diagnosis or nature of illness, injury or symptom. Relate diagnosis to procedure in column E by reference to numbers 1, 2, 3, etc.
1.
2.
3.
24.
A
B
C
D. Description: Explain unusual services or circumstances related to
E
F
G
H
Date of
Place of
Type of
procedures, medical services, or supplies furnished for each date given.
Diagnosis
Charges
Days
(Anthem
service
service
service
code
or
use only)
Procedure code. Circle one:
(see back)
Units
CPT IV or BSA
Internal use only
25. Total charges
To receive payment,
you must indicate your
Anthem identification
26. Patient account number
27. Anthem identification number
Use ADVANCE Plan stamp here
number
in Block 27.
28. Physician/provider name ____________________________________________________________
I certify that these
services were
Address__________________________________________________________________________
performed by me
or in my presence
City______________________________State ____________________________ZIP____________
under my
supervision.
Signature ________________________________________________________________________
00361CEMEN (7/09)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 391 C - Designation Of An Authorized Representative Form - Highmark Blue Shield - Pennsylvania
Legal
Form W-2 - Wage And Tax Statement - 2009, Form K-2 - Wage And Tax Statement (for Kentucky Department Of Revenue)
Financial
Related Categories
Parent category: Business