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MEDICAL BENEFITS SUBSCRIBER CLAIM FORM 2a-SUBSCRIBER'S LAST NAME 2b-FIRST NAME 2c-INITIAL 2d-SUBSCRIBER IDENTIFICATION NUMBER (Including Prefix) 2e-ADDRESS-NUMBER AND STREET 2f-CITY 2g-STATE 2h-ZIP CODEExc SUBSCRIBER /PATIENT INFORMATION 2i-PATIENT'S LAST NAME 2j-FIRST NAME 2k-INITIAL 2L-DATE OF BIRTH 2m-GENDER 2n-PATIENT'S RELATIONSHIP TO SUBSCRIBER M F SELF SPOUSE CHILD OTHER HEALTH INSURANCE INFORMATION 3a-IS THE PATIENT COVERED BY ANOTHER HEALTH INSURANCE PLAN (INCLUDING MEDICARE)? 3b-NAME OF OTHER POLICYHOLDER 3c-POLICY OR IDENTIFICATION NUMBER 3d-POLICY EFFECTIVE DATE: 3e-TYPE OF POLICY/COVERAGE: 3f-POLICYHOLDER'S DATE OF BIRTH: yyyy dd mm yyyy dd mm TWO-PERSON INDIVIDUAL FAMILY 3g-NAME AND ADDRESS OF OTHER INSURANCE CARRIER SECTION 2 If YES, please complete 3b-3g below YES NO Please Note-If the patient has other primary insurance, the Explanation of Benefits form(s) from the other health insurance plan must accompany this claim form, along with the matching itemized bill. MOTOR VEHICLE/WORK-RELATED INFORMATION SECTION 3 4a-ARE THE SUBMITTED EXPENSES RELATED, IN ANY WAY, TO A MOTOR VEHICLE OR WORK-RELATED ACCIDENT OR INJURY? NO YES If YES, please complete 4b & 4c below 4b-TYPE OF ACCIDENT: WORK MOTOR VEHICLE OTHER yyyy dd mm 4c-DATE OF ACCIDENT OR INJURY: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals information concerning any fact material thereto, for the purpose of misleading, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of each violation. SECTION 5 SIGNATURE AND DATE DATE: SUBSCRIBER SIGNATURE: I CERTIFY THAT THE INFORMATION SUBMITTED IS ACCURATE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE THE RELEASE OF ANY RELEVANT INFORMATION TO MY INSURANCE CARRIER. yyyy dd mm SECTION 4 Please enter all information exactly as shown on your ID card 1b-ITEMIZED BILL(S) FOR SERVICES OR SUPPLIES MUST BE SUBMITTED WITH THIS FORM IN ORDER FOR REIMBURSEMENT TO BE CONSIDERED. THE ITEMIZED BILL MUST CLEARLY INDICATE ALL OF THE FOLLOWING: 1-PATIENT'S FULL NAME AND DATE OF BIRTH 2-NAME AND ADDRESS OF THE PROVIDER OF SERVICE ON THEIR OFFICE LETTERHEAD, INCLUDING PROVIDER CREDENTIALS AND EIN (TAX) AND/OR NPI NUMBER 3-DATE FOR EACH SERVICE RENDERED 5-CHARGE FOR EACH SERVICE RENDERED 6-VALID DIAGNOSIS CODE (DESCRIPTION OF ILLNESS/INJURY FOR SERVICES RENDERED) 7-COUNTRY MUST BE INDICATED AND ALL INFORMATION TRANSLATED TO ENGLISH FOR ANY SERVICE(S) NOT RENDERED IN THE USA 4-VALID PROCEDURE CODE (DESCRIPTION OF SERVICES RENDERED) FOR EACH CHARGE NO YES 1a-HAVE SUBMITTED EXPENSES BEEN PAID IN FULL BY YOU? SECTION 1 INFORMATION REQUIRED FROM SUBSCRIBER 8-PRESCRIPTION NUMBER AND NAME OF PRESCRIBING PHYSICIAN MUST BE INDICATED ON RX/MEDICINE BILLS A nonprofit independent licensee of the BlueCross BlueShield Association PLEASE REVIEW AND LEGIBLY COMPLETE ALL SECTIONS (1-5) OF THIS FORM Please Note-If you do not have all of the required information, please contact the provider of service for assistance prior to submitting your claim. Failure to supply all of the required information may result in delayed processing and/or subsequent return or denial of your claim submission. If your address has changed or is incorrect, please call our Customer Service Department at the telephone numbers listed on your identification card. Please Note-If a participating provider rendered the service(s) being submitted, payment will be made directly to the provider. P.O. Box 21146 Eagan, MN 55121-0146 Mail completed form and all required information to: MSA-1f, Rev 1/2020 A11y IH 12/10/2020 SIGN