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How to complete the Master Medical claim form
Please: Separate receipts, forms and vouchers for each individual. Complete a separate claim form for each member. Staple or paper clip receipts to the appropriate claim form. Please do not glue or tape. If applicable, attach a copy of your Explanation of Medicare Benefits form or Medicare voucher.
If another insurance carrier has made a payment on the claim, please include the statement showing what was paid.
Save copies of all items for your records.
| Item | Instruction |
|---|---|
| 1-2 | Enter the subscriber's (i.e. card holder's) name as it appears on their BCBSM identification card. |
| 3 | Enter your mailing address. |
| 4-5 | Copy these numbers from your ID card. |
| 6-12 | Patient information: Fill in information on the person who received services or supplies. Do not use nicknames such as Suzie or Donnie. Please use full given name, such as Susan or Donald. |
| 13-24 | Do you have other health care coverage? If so, please include the following information: Name of other company and spouse's date of birth. |
| 15 | Remember that the subscriber must sign and date the claim form. |
