Blue Cross Blue Shield Association Member Claim FormBlue Cross Blue Shield Association Member Claim Form
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Member Claim Form
Do not file prescription drugs on this form. Type or use blue or black ink to complete.
• Visit for prescription drug, dental and international claim forms, or call the toll-free number on your ID card.

Filing Requirements:
• Complete a separate claim form for each covered family member.
• Enclose itemized receipts and make copies for your records. See Section IV for required information.
• Do not file a claim if the provider is filing for the same services.
• Attach Explanation of Benefits if these services are covered by another insurance policy.
• Claims must be filed within 18 months from the date services were received, or they will be denied.
• Please see Section VI for mailing information.

Any claim filed without the required documentation listed above will be returned.
SECTION I: Patient Information

Please enter the subscriber number from your ID card.

Begin with
letter prefix

2 digits following member’s
name (see ID card)