Instructions
Important: Do Not file this form if your Provider of Service is submitting these charges to Blue Cross and Blue Shield of Texas. Please complete every item on claim form.
Insured’s/Subscriber’s Name, Address and Employment Status
Please show the insured’s/subscriber’s name exactly as it appears on the Blue Cross and Blue Shield of Texas identification card and specify the current address including the ZIP code. Check the appropriate box indicating the insured’s/subscriber’s employment status. If retired, give the date of retirement.
Patient Information
Make sure the group number and identification number are exactly as shown on the insured’s identification card. List the patient’s full name; no nicknames or initials please. Check the appropriate blocks for the patient’s sex and relationship to the insured. Ensure the patient’s correct date of birth is shown.
Type of Treatment Received
Check only one treatment type (injury, illness, pregnancy or preventive care) and specify the date of injury, date of first symptom, date of conception or date preventive care was received. You may attach multiple itemized statements if they are for one type of treatment (example: illness only, preventive care only).
Diagnosis or Symptoms of Illness or Injury
Give the diagnosis or a brief description of symptoms. If preventive care services were received, state the type of care (routine physical, hearing exam, vision exam or immunization diagnosis, etc.).
If Illness or Injury is in any way work related
Check the appropriate box and enter the name and address of the employer.
If Motor Vehicle Injury
Check the appropriate box.
Other Insurance
Please check the appropriate box. If “yes,” complete the required information.
Medicare Information
Please check the appropriate box concerning Medicare eligibility. If “yes,” show the effective date and give the Medicare identification number.
Medicare enrollees should include a copy(s) of the Medicare Explanation of Benefits Form(s) (EOB) with their itemized statements unless the patient is actively employed and requires group coverage to pay primary.
Insured’s Signature, Date and Daytime Phone
Please sign and date this form and attach your physician’s itemized letterhead statement(s).