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Get Highmark BCBS CLM-038 2003-2021

TIAL) (STATE) (ZIP CODE) 4. EMPLOYEE’S PHONE NUMBER 3. EMPLOYEE’S IDENTIFICATION NUMBER ( ) AREA CODE PATIENT INFORMATION: 5. PATIENT’S NAME (LAST) 6. PATIENT’S BIRTH DATE MONTH DAY (FIRST) 7. PATIENT’S SEX YEAR ❏ MALE ❏ FEMALE ❏ YES 10. WAS AN ACCIDENT INVOLVED? IF YES WHEN? MONTH DAY YEAR 8. PATIENT’S RELATIONSHIP TO MEMBER ❏ SELF ❏ SPOUSE 9. ❏ AUTO ❏ OTHER: DIAGNOSIS OR NATURE OF ILLNESS ❏ CHILD ❏ NO WHERE: (MIDDLE INITIAL) ❏ WORK ( .

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