Medical Claim Form

Please use a separate claim form for each patient and provider. Your cooperation in completing
all items on the claim form and attaching all required documentation will help expedite quick
and accurate processing. SEE REVERSE SIDE FOR COMPLETE INSTRUCTIONS.

SECTION 1: PATIENT INFORMATION

Last name First name M.I.

Does the patient have other health insurance coverage? Relation to subscriber Sex Date of birth (MM/DD/YYYY)
Male
Yes No Self Spouse Son Daughter Female
Name of other health insurance company Group no. Employer name Policy no.

SECTION 2: SUBSCRIBER INFORMATION (on Anthem Blue Cross and Blue Shield ID card)
Identification no. Group no.

Last name First name M.I.

Street address (please include apt. no.) City State ZIP code

Home phone no. Work phone no. Date of birth (MM/DD/YYYY)

SECTION 3: MEDICAL INFORMATION

HEALTH CARE SERVICES: Use this section to report any COVERED health service that has not already been reported to this Anthem Blue Cross and Blue Shield
Plan by the provider of service (the physician, clinical, ambulance company, private duty nurse, etc.) Attach itemized bill or photocopy. Please be sure that
duplicate bills are not submitted.
Where was the service rendered? Physician office Outpatient Inpatient Ambulance
Medical equipment supplier Pharmacy Laboratory Other
Was this medical expense the result of an accident?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Was this condition or injury job related?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Have you filed for Workers’ Compensation?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
When did this injury or accident occur? (MM/DD/YYYY)
Date of service Diagnosis code Procedure code Tax ID Amount

Total $ 0.00
BILLS MUST BE ITEMIZED
Cancelled checks, cash register receipts and non-itemized “balance due” statements cannot be processed. Each itemized bill must include:
}}Name and address of provider }}Amount charged for each service
(doctor, hospital, laboratory, ambulance service, etc.) }}Diagnosis code
}}Name of patient }}Procedure code
}}Service provided }}Tax ID
}}Date of service

I certify that, to the best of my knowledge, the information on this Medical Claim Form is true and correct. I authorize the release of any medical information
necessary to process this claim.
Signature Printed name Date (MM/DD/YYYY)
X
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 HOW TO USE THIS FORM
Dear Member:
Usually, all providers of health care will bill us for services to you and your enrolled dependents. This is the preferred procedure. You are not bothered with
claim forms and we often need more details than are ordinarily provided on bills to patients.
Sometimes, a physician or an ambulance company may not bill us, for example, they may send the bill directly to you. In either instance, we have no way
of knowing about your claim. This Medical Claim Form was developed to notify us of any covered health service for which we have not already been billed.
Please read the following instructions about how to report Health Care Services.
We are happy to serve you.
SECTION 1: PATIENT INFORMATION
Use this section to identify the patient.

SECTION 2: SUBSCRIBER INFORMATION (on Anthem Blue Cross and Blue Shield ID card)
Use this section to identify the subscriber. Some of this information may be found on your Anthem Blue Cross and Blue Shield card.

SECTION 3: MEDICAL INFORMATION

HEALTH CARE SERVICES: Use this section to report any COVERED health service that has not already been reported to this Anthem Blue Cross and Blue Shield
Plan by the provider of service (the physician, clinical, ambulance company, private duty nurse, etc.) Attach itemized bill or photocopy. Please be sure that
duplicate bills are not submitted.

ANA CENTRAL MEDICAL CLAIM FORM INSTRUCTIONS:

Please send claims to:
Anthem Blue Cross and Blue Shield
PO Box 105187
Atlanta, GA 30348-5187

If you have questions or need any assistance, please call the number listed on your Member ID card.

Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT),
Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide
administrative services for self-funded plans and do not underwrite benefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies;
Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association.
®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association.

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