Blue Cross Blue Shield Association Medical Claim Form 2Blue Cross Blue Shield Association Medical Claim Form 2
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3

HEALTH INSURANCE CLAIM FORM

Send Completed Claim Form To:
Blue Cross and Blue Shield of Illinois
P.O. Box 805107
CHICAGO, IL 60680-4112

NOTICE TO ALL PARTIES COMPLETING THIS FORM: It is fraudulent to fill out this form with information
you know to be false or to omit important facts. Criminal and/or civil penalties can result from such acts.

PLEASE PRINT OR TYPE CLEARLY

ID NUMBER -- Copy this from your Blue Cross and Blue Shield Identification Card.
GROUP NUMBER:

IDENTIFICATION NUMBER:

PATIENT INFORMATION -- A separate claim form must be completed for each family member.
PATIENT’S FULL LEGAL NAME (Last, First, Middle Initial)

SEX:

SOCIAL SECURITY NUMBER (optional):

Male
Female
PATIENT IS:

Member

Spouse

Child

DATE OF BIRTH
Month

Day

Year

___ ___ ___/ ___ ___/ ___ ___ ___ ___

OTHER, please explain relationship:

IF CLAIM IS FOR CHILD 19 OR OLDER—IS CHILD:

A full-time student?

Yes

No

Handicapped?

Yes

No

PAYEE:

MAKE PAYMENT TO THE PROVIDER (hospital, doctor etc.