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MEDICAL CLAIM FORM (Instructions for filing on second page) PARTICIPANT’S NAME (Last, First, M.I.) MEMBER ID NUMBER HOME ADDRESS (Street, City, State, Zip) IS THIS A NEW ADDRESS? Yes No PATIENT’S NAME (Last, First, M.I.) MALE FEMALE DATE OF BIRTH (MM/DD/YYYY) RELATIONSHIP Self TO PARTICIPANT Spouse Child DESCRIBE THE ILLNESS, INJURY OR REQUIRING TREATMENT: IF ILLNESS OR INJURY RESULTED FROM AN ACCIDENT, WAS IT DUE TO: AUTO EMPLOYMENT OTHER (Briefly Describe) INDICATE DATE OF ACCIDENT (MM/DD/YYYY) OTHER HEALTH INSURANCE: Is the patient covered by additional health insurance through an employer, a group such as a professional organization or any other group health insurance, including other Blue Cross and/or Blue Shield coverage? YES NO If yes, please complete this section. NAME AND ADDRESS OF INSURING COMPANY (Street, City, State, Zip) EFFECTIVE DATE (MM/DD/YYYY) TERMINATION DATE (MM/DD/YYYY) NAME OF POLICYHOLDER (Last, First, M.I.) DATE OF BIRTH (MM/DD/YYYY) IDENTIFICATION NUMBER (Including all letters & numbers) I CERTIFY THAT THE ABOVE IS CORRECT AND COMPLETE AND THAT I AM CLAIMING BENEFITS ONLY FOR THE CHARGES INCURRED BY THE PATIENT NAMED ABOVE. Signature of Participant Date 4000 House Avenue P O Box 2266 Cheyenne, WY 82003-2266 11/17 ---PAGE BREAK--- INSTRUCTIONS FOR FILING CLAIMS 1. A separate claim form must be submitted for each family member. 2. Itemized bills for covered services, supplies and durable medical equipment MUST be attached and show: A. Name of patient and date of birth B. Date of service and charge for each C. Type of services/supplies/equipment received (surgery, office calls, crutches, etc.) D. Description of illness or accident E. Date of accident 3. Bills for prescription medication must include above information as well as: A. Patient’s Name B. Description of Illness or Accident C. Name of Drug D. Name of Pharmacy E. Prescribing Physician F. Date Purchased and Charge for Each Drug G. If actual drug receipt is not available, pharmacist signature is required 4. Questions on filing medical claims should be directed to: Member Services Center Blue Cross Blue Shield of Wyoming P O Box 2266 Cheyenne, WY 82003-2266 [PHONE REDACTED] 1.[PHONE REDACTED] NOTE: Balance due statements, cash register receipts, cancelled checks and cash receipts are not acceptable. ITEMIZED BILLS CANNOT BE RETURNED SAMPLE OF BCBS IDENTIFICATION CARD