Blue Cross Blue Shield Association Medical Claim Form 1Blue Cross Blue Shield Association Medical Claim Form 1
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®

P.O. Box 660044
Dallas, Texas 75266-0044

®

Claim Form
to Pay
Insured/Subscriber

Each item on this form needs to be completed.
Instructions for completion are listed on the reverse side.

Please Print or Type

1 Insured/Subscriber Name (Last, First, Middle Initial)
Mailing Address

2

Group Number

Insured/Subscriber Identification Number (from ID card)

Patient's Full Name (Last, First, Middle)

City & State

Zip Code

Patient's Sex

Patient's Date of Birth

■ Male ■ Female
Insured Employed?

■ Yes

■ No

■ Retired

Date of Retirement
Month
Date
Year
/
/

Month

Day

Year

_____ /_______ /____

Patient's Relationship to Insured
1. ■ Self 2. ■ Spouse 3. ■ Child 4.■ Other (explain)

3 Type of treatment received:

____________________
Month

Check only one type and attach itemized statements.
Please use a separate claim form for each different type
of treatment.
*Please note: Preventive care includes immunizations,
routine well baby care, routine physical examinations,
vision and he