Follow the steps to complete your claim form online.

1. Click ‘Get Form’ button to obtain the form and access it for completion.
2. Fill out the 'Insured/Subscriber Name' section, entering the last name, first name, and middle initial. Include the current mailing address, city, state, and zip code.
3. Provide the group number and insured/subscriber identification number as shown on the identification card, followed by the patient's full name, date of birth, sex, and relationship to the insured.
4. Indicate the type of treatment received by checking only one type, and provide the relevant dates for injury, first symptom, conception, or service.
5. In the diagnosis section, describe the diagnosis or symptoms of the illness or injury and provide details for any preventive care received.
6. Respond to whether the illness or injury is work-related by checking 'Yes' or 'No' and provide the name and address of the employer if applicable.
7. If the injury involved a motor vehicle, denote this by checking the appropriate box.
8. Complete the section on other health benefits plans by indicating whether the patient is covered under any other plan and providing the necessary information.
9. Fill in the Medicare section regarding the patient's Medicare eligibility, ensuring to include effective dates and identification numbers as needed.
10. Certify the accuracy of the information by signing and dating the form, and provide a daytime telephone number.
11. Ensure that itemized bills for the covered services and supplies are attached. Review the form for completeness before submission.
12. Once all sections are completed and verified, save changes, download, print, or share the form as needed.

Get started on your BCBS claim form today and ensure all necessary information is filled out accurately.