Get Fax Number Of Bluecard Service Center 23255 Form

Filling out the Fax Number Of Bluecard Service Center 23255 Form online can streamline the process of submitting claims for services received outside of the United States. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide patient information in section 1. Enter the alpha prefix identification number, the patient’s name as it appears on their Blue Cross Blue Shield identification card, and the date of birth following the MM/DD/YYYY format. Also, fill in the patient's sex and relationship to the subscriber.
3. In section 2, indicate if the patient has other health insurance. If yes, complete subsections 2A through 2K with the required details about the other insurance provider, the type of policy, and coverage status.
4. Fill out section 3 regarding diagnosis. Describe the illness or injury requiring treatment, and indicate if the treatment was due to a work-related condition or accident. Provide details of the accident if applicable.
5. In section 4, list the charges for services received. Include each type of service or provider on a separate line, ensuring to attach itemized bills for verification. Fill in the name and address of the provider, the type of provider, a description of the service, dates of service, and the respective charges.
6. Section 5 requires you to select the payment option. Either choose to have payment made to the subscriber or directly to the provider. Fill in the necessary details for payment processing, like currency preferences and banking information, if applicable.
7. In section 6, ensure to sign and date the form. This signature certifies that the information provided is complete and correct, and grants authorization for the necessary medical information to be shared.
8. Finally, review all entered information for accuracy, save the changes, and prepare to download or print the form for submission. Ensure that you attach any required itemized bills and supporting documentation.

Start filling out the Fax Number Of Bluecard Service Center 23255 Form online today to ensure timely processing of your claims.