Please complete every item on claim form. This completed form, together with the itemized bills, should be submitted to: Blue Cross and Blue Shield of Illinois.

If you are filing a claim, please fill out the reverse side of this form. Help us avoid unnecessary delays by answering all questions completely. Help us ...

Check only one type and attach itemized statements. Please use a separate claim form for each different type of treatment. Please note: Preventive care includes ...

Please complete every item on claim form. This completed form, together with the itemized bills, should be submitted to: Blue Cross and Blue Shield of Illinois.

If you are filing a claim, please fill out the reverse side of this form. Help us avoid unnecessary delays by answering all questions completely. Help us ...

Attach original itemized pharmacy receipts provided with your prescription. Be sure that all the required information is visible (staple to the top of the form, ...

Claim Reporting/Results/Resolution ; Check and Voucher Request Form, Commercial only ; Medicare Reconsideration Form, Commercial only ; Provider Refund Form ...

Download a claim form for medical services, pharmacy services or overseas care. Medical Forms Health Benefits Claim Form

Use this form to file a claim when your doctor doesn't file the claim for you. You should send this completed claim form as soon as possible after you get care.

The Blue Cross Blue Shield Global Core International Claim Form is to be used to submit institutional and professional claims for benefits for covered ...