Get Ks Bcbs 34-4 Form 2020-2025

Filling out the KS BCBS 34-4 Form online can be a straightforward process when you have the right guidance. This comprehensive guide is designed to help you navigate each section of the form with ease and confidence.

Follow the steps to fill out your form accurately

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section 1, enter patient information. Fill in first name, last name, middle initial, identification number, date of birth, and residential address. Provide home and cell phone numbers, email address, and group number. If the address has changed, mark the change of address checkbox.
3. In Section 2, fill out alternate payee information if applicable. Include the first name, last name, middle initial, suffix, and contact details of the person to be reimbursed.
4. Section 3 addresses information about your injury or illness. Indicate if the service relates to an accident by selecting 'Yes' or 'No.' If 'Yes,' provide the date and details of how the accident occurred. Specify the location and whether it relates to Workmen’s Compensation.
5. If your injury involves a motor vehicle, proceed to Section 4. Answer if the injury resulted from physical contact with a motor vehicle, and provide the required information regarding personal injury protection and any motor vehicle insurance.
6. Section 5 pertains to other group health insurance. Indicate whether the patient is entitled to benefits from other insurance and provide necessary details such as the insurance carrier's name and policy number.
7. In Section 6, indicate Medicare coverage. Provide information regarding Medicare hospital insurance, medical insurance, and prescription drug insurance, if applicable.
8. Section 7 requires additional information and authorization. Ensure to attach necessary itemized bills for prescriptions and services provided. Submit the completed claim within the specified timeframe to the appropriate address.
9. Finally, review all information carefully, then save your changes. You can download, print, or share your completed form as needed.

Start filling out your KS BCBS 34-4 Form online today for a smooth claims process.