Claim Form

to Pay Insured/Subscriber
P.O. Box 805107 Chicago, Illinois 60680-4112

Each item on this form needs to be completed.

Instructions for completion are listed on the reverse side.
Please print or type.
Insured/Subscriber Name (Last, First, Middle Initial) Group Number Insured/Subscriber Identification Number (from ID card)

Mailing Address Patients Full Name (Last, First, Middle)

1 City and State ZIP Code 2 Patients Sex Patients Date of Birth Month Day Year

__________ /__________ /_____________

Insured Employed? Date of Retirement:
Month Day Year Patients Relationship to Insured

Yes No Retired __________ /__________ /_____________ Self Spouse Child Other (explain) _______________________________________

Type of treatment received: Month Day Year

Check only one type and attach itemized statements. Please use Injury Date of accident: __________ /__________ /_____________
a separate claim form for each different type of treatment.
3 Illness Date of first symptom: __________ /__________ /_____________
Please note: Preventive care includes immunizations, routine
well baby care, routine physical examinations, vision and Pregnancy Date of conception: __________ /__________ /_____________
hearing exams. Preventive Date of service: __________ /__________ /_____________

Describe: Diagnosis, symptoms of illness or injury or explain preventive or routine care received.

_________________________________________________________________________________________________________________________________________________________________________
4
_________________________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________

5 Was illness or injury work connected? Yes No Name and address of employer

______________________________________________________________________________________________
6 If injury, was a motor vehicle involved? Yes No ______________________________________________________________________________________________

Is patient covered under any other health benefits plan (besides Medicaid, Medicare or CHAMPUS)? Yes No
Insurance Co. _____________________________________________________________________ Month Day Year

Address __________________________________________________________________________ Effective date of coverage ___________ /___________ /______________

7 Employer _________________________________________________________________________ Sex of Insured Male Female
Insured name ____________________________________________________________________ Date of birth of insured ___________ /___________ /______________
Policy # ___________________________________________________________________________ Relationship to patient _________________________________________________________

If the other coverage is primary, attach the other insurance companys Explanation of Benefits.

Medicare Is the patient: Month Day Year

a) Entitled to benefits under Medicare insurance (Part A)? Yes No Effective ___________ /___________ /______________
b) Entitled to benefits under Medicare insurance (Part B)? Yes No Effective ___________ /___________ /______________
8
c) Entitled to benefits under Medicare due to a disability? Yes No Effective ___________ /___________ /______________

Patients Medicare Identification Number. (From Medicare ID card) ___________________________________________________________________________________________________

I certify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named above.
Authorization is hereby given to any Hospital, Physician, Dentist, Provider, Insurance Carrier or other entity to give Blue Cross and
Blue Shield of Illinois, upon request, any medical information which the Plans in their judgment deem necessary to the adjudication of this
claim. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to
9
fines and confinement in state prison.

Signature of Insured Date Daytime telephone number

Total amount for ALL covered services and supplies received. $

10
Itemized Bill(s) for covered services and supplies must be attached. (See Instructions on reverse side.)
228934.1015

Important: DO NOT file this form if your Provider of Service is submitting
these charges to Blue Cross and Blue Shield of Illinois.
Insured/subscribers
1 name, address and
employment status
2 Patient information
Type of treatment
3 received
Diagnosis or symptoms
4 of illness or injury
If illness or injury is in
5 any way work-related
6 If motor vehicle injury
7 Other insurance
8 Medicare information
Insureds signature,
9 date and daytime
telephone number
Example of Itemized Bill Please remember to attach the original bill(s) to the claim form and make a copy
for your records. Itemized bills cannot be returned.
Name of the person or
organization providing the
services or supplies.
Name of the patient
receiving the services
or supplies
10
NOTE: Bills for Private Duty
Nursing Service must show
the professional status of the
nurse (R.N. Registered
Nurse, L.V.N. Licensed
Vocational Nurse), the nurses
license number, and must be
accompanied by a statement
from your physician indicating
medical necessity and daily
nurses progress notes.
This completed form, together with the itemized bills, should be submitted to:
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Claim Form
to Pay Insured/Subscriber
Instructions
Please complete every item on claim form.
Please show the insured/subscribers name exactly as it appears on the Blue Cross and Blue Shield of Illinois
identification card and specify the current address including the ZIP code. Check appropriate box indicating the
insured/subscribers employment status. If retired, give date of retirement.
Make sure the group number and identification number are exactly as shown on the insureds identification
card. List patients full name; no nicknames or initials. Check the appropriate blocks for the patients sex and
relationship to the insured. Ensure the patients correct date of birth is shown.
Check only one treatment type (injury, illness, pregnancy or preventive care) and specify date of injury, date
of first symptom, date of conception or date preventive care was received. You may attach multiple itemized
statements if they are for one type of treatment (example: illness only, preventive care only).
Give diagnosis or a brief description of symptoms. If preventive care services were received, state the type of
care (routine physical, hearing exam, vision exam, immunization or diagnosis, etc.).
Check appropriate box and enter name and address of employer.
Check appropriate box.
Please check appropriate box. If yes, complete the required information.
Please check appropriate box concerning Medicare eligibility. If yes, show effective date and give Medicare
identification number.
Medicare Enrollees should include a copy(s) of the Medicare Explanation of Benefits Form(s) (EOB) with their
itemized statements unless patient is actively employed and requires group coverage to pay primary.
Please sign and date this form and attach your physicians itemized letterhead statement(s). The itemized
statement(s) should contain all the information shown in the following example:
Dayton Penridge, M.D. If you are submitting itemized bills
101 Fourth Street for a variety of services please use a
Healthville, U.S.A. separate claim form for each different
type of treatment (one for illness,
another for an injury, etc.).
For Professional Services Rendered To: Diagnosis Code:
Virginia E. Warowes (78659) Chest pain, other
Please cross out those charges which
3/1/15 G0206 Mammogram $XXX
were included on a previous claim.
3/1/15 19120 Excision of Cyst $XXX
3/1/15 19083 Biopsy, breast w/Ultrasound $XXX
3/6/15 90659 Flu Vaccine $XXX FOR OTHER THAN PRESCRIPTION
3/6/15 G0008 Flu Vaccine Administration $XXX DRUG CARD HOLDERS: Bills for
Prescription Drugs must show the
name of each drug, the prescription
number, the quantity dispensed, the
date of purchase, and the amount
Date each Description of the Charge for charged for each drug, If drug is
service or supply services or supplies each service generic then the pharmacist must
was provided provided or supply also indicate on itemized bill.
Blue Cross and Blue Shield of Illinois
P.O. Box 805107
Chicago, Illinois 60680-4112
228934.1015


If you, or someone you are helping, have questions, you have the right to get help and information in your language at no cost.To speak to an
interpreter, call the customer service number on the back of your member card. If you are not a member, or dont have a card, call 855-710-6984.

.
Arabic .855-710-6984
.

, , , ,
Chinese , , 855-710-6984

Si vous, ou quelqu'un que vous tes en train daider, avez des questions, vous avez le droit d'obtenir de l'aide et l'information dans votre langue
Franais
aucun cot. Pour parler un interprte, composez le numro du service client indiqu au verso de votre carte de membre. Si vous ntes pas
French
membre ou si vous navez pas de carte, veuillez composer le 855-710-6984.

Falls Sie oder jemand, dem Sie helfen, Fragen haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit
Deutsch
einem Dolmetscher zu sprechen, rufen Sie bitte die Kundenservicenummer auf der Rckseite Ihrer Mitgliedskarte an. Falls Sie kein Mitglied sind oder
German
keine Mitgliedskarte besitzen, rufen Sie bitte 855-710-6984 an.

, .

, .
Greek
, 855-710-6984.

... ,

. ,
Gujarati
855-710-6984 .

, , ,

, ,
Hindi
, 855-710-6984

Se tu o qualcuno che stai aiutando avete domande, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un
Italiano
interprete, puoi chiamare il servizio clienti al numero riportato sul lato posteriore della tua tessera di socio. Se non sei socio o non possiedi una
Italian
tessera, puoi chiamare il numero 855-710-6984.

. . 855-710-6984
Korean
.

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Din
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Navajo
had7t44g00 47 doodago bee n44h0zin7g77 1dingo koj8 hod77lnih 855-710-6984.

Jeli Ty lub osoba, ktrej pomagasz, macie jakiekolwiek pytania, macie prawo do uzyskania bezpatnej informacji i pomocy we wasnym jzyku.
Polski
Aby porozmawia z tumaczem, zadzwo pod numer podany na odwrocie karty czonkowskiej. Jeeli nie jeste czonkiem lub nie masz przy
Polish
sobie karty, zadzwo pod numer 855-710-6984.

, , , ,
. , ,
Russian . ,
855-710-6984.

Si usted o alguien a quien usted est ayudando tiene preguntas, tiene derecho a obtener ayuda e informacin en su idioma sin costo alguno. Para
Espaol
hablar con un intrprete comunquese con el nmero del Servicio al Cliente que figura en el reverso de su tarjeta de miembro. Si usted no es miembro
Spanish
o no posee una tarjeta, llame al 855-710-6984.

Kung ikaw, o ang isang taong iyong tinutulungan ay may mga tanong, may karapatan kang makakuha ng tulong at impormasyon sa iyong wika nang
Tagalog
walang bayad. Upang makipag-usap sa isang tagasalin-wika, tumawag sa numero ng serbisyo para sa kustomer sa likod ng iyong kard ng miyembro.
Tagalog
Kung ikaw ay hindi isang miyembro, o kaya ay walang kard, tumawag sa 855-710-6984.

Urdu
855-710-6984

Nu qu v hoc ngi m qu v gip c bt k cu hi no, qu v c quyn c h tr v nhn thng tin bng ngn ng ca mnh min
Ting Vit
ph. ni chuyn vi thng dch vin, gi s dch v khch hng nm pha sau th hi vin ca qu v. Nu qu v khng phi l hi vin
Vietnamese
hoc khng c th, gi s 855-710-6984.

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 Health care coverage is important for everyone.
We provide free communication aids and services for anyone with a disability or who needs language assistance.
We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.
Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail)
300 E. Randolph St. TTY/TDD: 855-661-6965
35th Floor Fax: 855-661-6960
Chicago, Illinois 60601 Email: CivilRightsCoordinator@hcsc.net

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:
U.S. Dept. of Health & Human Services Phone: 800-368-1019
200 Independence Avenue SW TTY/TDD: 800-537-7697
Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

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