Get Subscriber's Statement Of Claim - Eisb

Welcome to this guide on filling out the Subscriber's Statement of Claim - Eisb online. This form is essential for submitting claims when service providers do not submit them directly to Blue Shield. Follow this guide for a comprehensive walkthrough to ensure accurate and timely processing of your claim.

Follow the steps to complete your form online:

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the subscriber's name, using their last name, first name, and middle initial as needed. Follow this by entering the subscriber number, mailing address, group number, city, state, and ZIP code. Ensure that you select whether the address is new by marking 'Yes' or 'No.'
3. Next, provide the subscriber's date of birth in month/day/year format and select the appropriate gender. Indicate the relationship of the patient to the subscriber by choosing 'Self,' 'Spouse,' or 'Child.'
4. Briefly describe the patient's illness or injury, including the circumstances surrounding any injury. Specify if the patient was treated for an injury, illness, or pregnancy by ticking the corresponding box.
5. Enter the date of injury, onset of illness, or pregnancy. Indicate if the patient is retired by selecting ‘Yes’ or ‘No.’ If 'Yes,' provide the effective date of retirement.
6. Respond to the question regarding other health coverage, marking ‘Yes’ or ‘No.’ If 'Yes,' enter the policy ID number, name of the insuring company, and the address along with the name of the policyholder and effective date. Also, specify the type of plan: 'Group' or 'Individual.'
7. Indicate the patient's date of birth in month/day/year format and provide the name of the employer. Answer whether the condition was related to employment by selecting ‘Yes’ or ‘No.’
8. Indicate whether the patient has Medicare by selecting ‘Yes’ or ‘No.’ If 'Yes,' provide the date of birth and the effective dates for Part A and Part B of Medicare.
9. Lastly, sign in the designated space to certify the accuracy and completeness of the provided information. Include the date of signature.

Start filling out your documents online today!