INSTRUCTIONS: BLUE CROSS/BLUE SHIELD OF ALABAMA MEDICAL EXPENSE CLAIM

Those who are enrolled for medical insurance through Blue Cross/Blue Shield of Alabama should file the medical expense claim discussed in this article when their physician or provider does not file a claim. This form can be found on the website of the Alabama State Employees' Insurance Board, which administers Blue Cross/Blue Shield insurance to state workers.

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 1: In box 1, enter the patient's name.

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 2: In box 2, enter your contract number as shown on your identification card.

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 3: In box 3, enter your group number as shown on your identification card or place of employment.

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 4: In box 4, enter the patient's date of birth.

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 5: In box 5, indicate the patient's gender with a check mark.

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 6: In box 6, indicate the patient's relationship to the contract holder with a check mark. If not the person holding the policy, their spouse or child, explain.

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 7: In box 7, give the name, address and telephone number of the contract holder.

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 8: In box 8, indicate with a check mark whether the patient is covered under any other group health insurance plan. If so, give the name of the policy holder of that plan, the name and address of the insuring company, the policy identification number and the date on which it became effective.

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 9: In box 9, indicate if the patient's condition was related to their employment, an auto accident, or another accident or injury.

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 10: In box 10, enter the diagnoses.

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 11: In box 11, give the phone number, name and address of the ordering physician. Sign and date the bottom of the form.