Ppo Program Out-Of-Network Claim Form - Bcbs Pennsylvania printable pdf download

Independence

PPO PROGRAM

Blue Cross

OUT-OF-NETWORK CLAIM FORM

Benefits underwritten or administered by QCC Ins. Co.,

a subsidiary of Independence Blue Cross – independent

licensees of the Blue Cross and Blue Shield Association.

Please Mail To:

Personal Choice Claims

P.O. Box 69352

(see reverse side for instructions)

Harrisburg, PA 17106-9352

MEMBER’S NAME (First, Middle, Last)

IDENTIFICATION NUMBER

GROUP NUMBER

PRESENT ADDRESS STREET

NEW ADDRESS

CITY

STATE

ZIP CODE

PATIENT’S NAME (First, Middle, Last)

RELATIONSHIP OF PATIENT TO MEMBER

SEX

BIRTH DATE

SELF

SPOUSE

CHILD

MALE

HANDICAPPED DEPENDENT

OTHER

FEMALE

• Does the PATIENT have additional health insurance benefits?

YES

If yes, complete Part II:

II.

POLICYHOLDER’S NAME

BIRTH DATE

EMPLOYMENT STATUS OF POLICYHOLDER

ACTIVE

DISABLED

RETIRED

EFFECTIVE DATE:

RELATIONSHIP OF POLICYHOLDER TO MEMBER

OTHER INSURANCE CARRIER’S NAME IDENTIFICATION NO.

EFFECTIVE DATE

SELF

SPOUSE

CHILD

OTHER _________________

TYPE(S) OF COVERAGE

HOSPITALIZATION

MEDICAL-SURGICAL

DENTAL

VISION

DRUG

MAJOR MEDICAL

OTHER __________________________________________________________________________________________________________________________

CONTRACT COVERS

POLICYHOLDER ONLY

POLICYHOLDER AND SPOUSE

POLICYHOLDER AND CHILD(REN)

FAMILY

• Is the PATIENT entitled to benefits under MEDICARE HOSPITALIZATION Insurance (Part A)?

YES

EFFECTIVE DATE:

MEDICARE ID NUMBER __________________________

• Does the PATIENT receive benefits under MEDICARE MEDICAL Insurance (Part B)?

YES

EFFECTIVE DATE:

MEDICARE ID NUMBER __________________________

If you answered “YES” to either of the above, give employment status of the member listed in Part “I”:

ACTIVE

RETIRED

DISABLED

III.

• DESCRIBE CONDITIONS FOR WHICH YOU ARE REQUESTING BENEFITS AT THIS TIME:

TYPE OF INJURY/ILLNESS

NAME OF DOCTOR TREATING INJURY/ILLNESS

DATE OF FIRST SYMPTOMS

A. _______________________________

_________________________________________________

______________________________

B. _______________________________

_________________________________________________

______________________________

(Attach additional information, if necessary)

• WERE SERVICES RELATED TO HOSPITALIZATION?

YES

If yes,

Give date of admission

Give date of discharge

Hospital Name __________________________________________

Admitting Physician __________________________________________________

• WERE EXPENSES DUE TO AN ACCIDENT?

YES

If yes, give type/place of accident:

Give date of accident

Auto

Work

Other (specify) ________________________________________________________

IV.

I certify that the information provided on this claim form is correct and complete, and that I am claiming benefits only for charges actually incurred by the

patient named. I authorize any hospital, physician or other provider who participated in the care and treatment of the patient to release to Independence

Blue Cross all medical or other information requested for the processing of this claim. I hereby agree to reimburse Independence Blue Cross in full should

this claim be incorrectly paid. Any person who knowingly and with intent to defraud any insurance company or other person files an application for

insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact

material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

_____________________________________________________________

________________________

_________________________

MEMBER’S SIGNATURE

DATE

(AREA CODE) HOME PHONE

(AREA CODE) WORK PHONE

09517 (03/09)