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.
PATIENT INFORMATION -- A separate claim form must be completed for each family member.
PATIENT’S FULL LEGAL NAME (Last, First, Middle Initial)
SOCIAL SECURITY NUMBER (optional):
DATE OF BIRTH
___ ___ ___/ ___ ___/ ___ ___ ___ ___
OTHER, please explain relationship:
IF CLAIM IS FOR CHILD 19 OR OLDER—IS CHILD:
A full-time student?
MAKE PAYMENT TO THE PROVIDER (hospital, doctor etc.