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ATION Identi f ication Number Subscriber's Last Name First Name Address - Number and Street Middle Initial City State Zip Code Employer's Name PATIENT INFORMATION (Use a separate f orm f or each patient) Patient's Last Name 1. 2. Middle Initial First Name Sex Patient Is: (Check one) Male 1. Subscriber (Contract holder) Female 2. Spouse (To contract holder) 3. 4. 5. Mo W A S TRE A T M EN T F OR: (I f y e s, g i v e i d ent i f i ca t i on num b e r and e f f e c t i v e da t e) M e.

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BCBS FEP: 1-800-411-BLUE (2583) BCBS FEP Dental: 1-855-504-BLUE (2583) BCBS FEP Vision: 1-888-550-BLUE (2583)

Subscriber name and Subscriber ID refers to who the primary insured person is, and the number that our office will need to file the claim. This section may also show Member name and Member ID if your coverage includes others, such as family members.

Blue Cross Blue Shield of Mass (Payer ID CBMA1) ACS CONSULTING SERVICE (Payer ID 72468)

Health Insurance today Chapter 11, QuestionAnswer The outpatient pretreatment authorization plan (OPAP) is also known as: precertification What title is listed on the BCBS identification cards for federal employees? government-wide service benefit plan BCBS Medicare supplemental plans are also known as? medigap32 more rows

04-1045815 is the Federal Tax ID (FID) for Blue Cross Blue Shield of Massachusetts for Health Care tax filing purposes. You won't receive a Form 1095-HC if: You're under 18 years old. You have a dental and/or vision-only plan through Blue Cross.

You can submit claims electronically or use the the direct claims entry link on our provider portal at providers.bcidaho.com. We process all claims (including denials and payments) on all claims within 90 days of receipt.

Your member number, also known as your identification number, is listed directly below your name. You'll need this information when receiving medical services at the doctor or pharmacy, or when calling customer service for assistance.

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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
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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 workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
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