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SUBSCRIBER S STATEMENT OF CLAIM IMPORTANT INSTRUCTIONS This form is to be used ONLY when the Provider of Service does not submit your claim directly to Blue Shield. Check with the Provider to be sure no claim has been submitted* Duplicate claims will not only be rejected but may delay payment of the original claim* EXCEPTIONS USE A SEPARATE FORM FOR A. EACH MEMBER OF THE FAMILY PRIMARY MEDICARE COVERAGE A. Submit claim to Medicare first. B. Complete Boxes 1 and 4 only. C. Attach your Explanation of Medicare Benefits form and a copy of itemized services to this claim and send all to Blue Shield. FOREIGN CLAIMS Any services rendered outside of the United States or its territories must include the US currency exchange rate or value and the translation for all billed services. B. EACH DIFFERENT PROVIDER OF SERVICE C. EACH ITEMIZED BILL PRINT OR TYPE FILL IN ALL ITEMS COMPLETELY SIGN YOUR NAME IN THE SPACE PROVIDED Failure to comply with these instructions may result in your claim being del....

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How to fill out the Subscriber Statement Form online

Filling out the Subscriber Statement Form online can be straightforward if you follow the right steps. This guide will provide you with clear, step-by-step instructions to help ensure your form is completed correctly and efficiently.

Follow the steps to fill out the Subscriber Statement Form

  1. Click the ‘Get Form’ button to access the Subscriber Statement Form and open it in your chosen editor.
  2. Enter your personal information in the Subscriber Information section, including your full name, subscriber number, address, group number, city, state, and zip code. Make sure to indicate if your address is new.
  3. Input your date of birth and indicate the name of the patient, their sex, and your relationship to the subscriber (self, spouse, or child).
  4. Briefly describe the patient's illness or injury and specify how the injury occurred, if applicable. Also, enter the date of the injury or the onset of the illness or pregnancy.
  5. Answer whether the patient has other health coverage and if they are retired. If applicable, provide the policy identification number and the effective date of the other coverage, along with the name and address of the insuring company.
  6. Indicate if the condition was related to employment. If the patient has Medicare, provide their date of birth and the effective dates for Part A and Part B.
  7. Sign your name in the provided space, certifying that the information is accurate and complete. Include the date of signing.
  8. Finally, review the form for completeness and accuracy. Once satisfied, you can save changes, download, print, or share the form as needed.

Complete your Subscriber Statement Form online today for efficient processing of your claim.

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Claims should be submitted to Blue Shield of California via the Real-Time Claims web tool or electronically using Electronic Data Interchange, though they can also be submitted by mail.

How to Fill Care Health Insurance Claim Reimbursement Form Step 1: Fill Out the Details of the Primary Insured. ... Step 2: Disclose the Insurance History of the Person Filing Claim. ... Step 3: List Down the Details of the Insured Person Hospitalized. ... Step 4: Enter the Hospitalization Information.

The person who pays for health insurance premiums or whose employment is the basis for membership in the insurance plan. For example, if you have health insurance through your spouse's health insurance plan, he or she is the primary subscriber.

What is the first step in completing a claim form? Check for a photocopy of the patient's insurance card.

Filing a health insurance claim means you're requesting reimbursement or direct payment for medical services that you've already received. The way to obtain benefits or payment is by submitting a claim via a specific form or request.

To file a claim, you must submit a Medi-Cal Claim Form for Beneficiary Reimbursement. The claim form must be filled out in blue or black ink; • The claim form must have an original signature (no copies will be accepted); The Claim Form must include: • A photo copy of your Medi-Cal Beneficiary Identification Card (BIC).

Dedicated Provider appeals line: Phone:(800) 541-6652. HMO and PPO: Blue Shield of California Initial Appeal Resolution Office. P.O. Box 272620. Chico, CA 95927-2620. Blue Shield 65 Plus (HMO): Blue Shield 65 Plus. Medicare Provider Appeals Department. P.O. Box 272640. Chico, CA 95927-2640. Fax: (855) 895-3501.

Reimbursement Claim refers to the type of claim wherein an insured must pay for the medical costs and treatment out of their pocket and later claim the bill from the insurance provider. For this kind of claim, the insured can visit any hospital for treatment and not necessarily the empanelled cashless hospital.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232