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

Call your local Blue Cross and/or Blue. Shield Plan before submitting your claim for such services; they will send you additional forms, if needed. FOR PATIENTS ...

PLEASE ATTACH ITEMIZED BILLS. NAME OF PROVIDER MAKING CHARGE. DESCRIPTION OF CHARGE. DATE OF SERVICE OR PURCHASE. CHARGE. (Doctor, Hospital, Pharmacy, etc.

This Overseas Medical Claim Form is to be used to submit a claim for benefits for covered services received outside the United States, Puerto. Rico, and the ...

Direct Reimbursement Claim Form. Important Information: 1. Use this form to request reimbursement for services received from providers who do NOT ...

Items 1 through 14 of this form must be completed by the subscriber or spouse, and items 15 through 23 are to be completed by the dentist. When the ...

All forms must be signed, then either faxed or mailed. General forms. FEP claim forms (fepblue.org) - A one-stop source for FEP claim forms.

Federal Employee Program (FEP) members use this form to file a medical claim. ID: 10407.

Instructions · Download CMS 1500 or UB04 form · Print and complete form · Mail paper claim form and any supporting documents to. Blue Cross NC PO Box 35. Durham, ...

You must file a paper claim for any covered drugs or supplies you purchase at Non-preferred retail pharmacies. Contact your Local Plan or call 800-624-5060.