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IDENTIFICATION NUMBER | 2.GROUP NUMBER OR ENROLLMENT CODE | 3. PATIENT’S NAME (FIRST, MIDDLE INITIAL, LAST) |  |  |\n| --- | --- | --- | --- | --- |\n| 4. PATIENT’S DATE OF BIRTH | 5. PATIENT’S SEX | 6. PATIENT’S RELATIONSHIP TO SUBSCRIBER: |  |  |\n| MO DAY YEAR\u003Cbr>| FEMALE q MALE q | EE\u003Cbr>SELF q | SP CH\u003Cbr>SPOUSE q CHILD q OTHER q EXPLAIN:   |  |\n| 7. SUBSCRIBER’S NAME (FIRST, MIDDLE INITIAL, LAST) |  |  |  | 8. DAYTIME TELEPHONE NUMBER (INCLUDE AREA CODE)\u003Cbr>( ) — |\n\n9. SUBSCRIBER’S ADDRESS (STREET, CITY, STATE, ZIP CODE) CHECK IF NEW ADDRESS q  \n\n| 10. IS PATIENT COVERED UNDER OTHER HEALTH INSURANCE? NO q YES q IF YES, NAME OF OTHER INSURANCE COMPANY   |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| NAME OF POLICY HOLDER   IS PATIENT COVERED UNDER MEDICARE? NO q YES q\u003Cbr>IF YES, PART A q PART B q MEDICARE HIC NUMBER   |  |  |  | |  |  |  |  |\n| IS PATIENT ACTIVELY EMPLOYED? NO q YES q IF YES, NAME OF EMPLOYER 2   |  |  |  |  |  |  |  |  |\n| 11. WAS PATIENT’S CONDITION DUE TO: AUTO ACCIDENT? NO q YES q ANY OTHER ACCIDENTAL INJURY? NO q YES q WORK RELATED ACCIDENT OR CONDITION? NO q YES q\u003Cbr>MEDICAL EMERGENCY? NO q YES q MO DAY YEAR NO q YES q\u003Cbr>IF AN ACCIDENT, GIVE THE DATE OF THE ACCIDENT     WAS ANOTHER PARTY AT FAULT?\u003Cbr>MO DAY YEAR\u003Cbr>IF MEDICAL EMERGENCY GIVE DATE SYMPTOMS BEGAN  \u003Cbr>\u003Cbr>\u003Cbr>IF YES, ATTACH A STATEMENT WITH DETAILS (SEE ACCIDENTAL INJURY ON THE REVERSE SIDE) |  |  |  |  |  |  |  |  |\n| 12.WAS PATIENT HOSPITALIZED? NO q YES q\u003Cbr>MO DAY YEAR\u003Cbr>ADMISSION DATE     |  |  | IF YES, COMPLETE THE FOLLOWING:\u003Cbr>MO DAY YEAR\u003Cbr>DISCHARGE     |  | NAME OF HOSPITAL\u003Cbr>NAME & ADDRESS OF\u003Cbr>ADMITTING PHYSICIAN |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n| 13.ARE BILLS FOR A CONSULTATION ATTACHED? NO q |  |  | YES q IF YES, GIVE NAME OF PHYSICIAN WHO REQUESTED THE CONSULTATION\u003Cbr>WAS THE CONSULTATION REQUESTED TO OBTAIN A SECOND SURGICAL OPINION?\u003Cbr>WAS SURGERY RECOMMENDED? |  |  |  |  |  |\n|  |  |  |  |  |  |  |  | NO q YES q\u003Cbr>NO q YES q |\n| 14.ARE BILLS FOR MATERNITY ATTACHED? NO q YES q IF YES, WHAT IS THE DATE OF THE LAST MENSTRUAL PERIOD? |  |  |  |  |  | MO | DAY YEAR\u003Cbr>|  |\n| 15.STATE THE DIAGNOSIS, SYMPTOMS, ILLNESS OR INJURY FOR THE EXPENSES CLAIMED\u003Cbr>HAS PATIENT HAD THESE SYMPTOMS/CONDITION |  |  |  | MO DAY YEAR\u003Cbr>GIVE DATE SYMPTOM(S) FIRST STARTED    \u003Cbr>MO DAY YEAR\u003Cbr>GIVE DATE PHYSICIAN FIRST SEEN     |  |  |  |  |\n| BEFORE? NO q YES q | IF YES, WHEN | MO\u003Cbr>\u003Cbr>DAY YEAR\u003Cbr>|  |  |  |  |  |  |\n\n\n|  |  |  |  | TO DATE | CHARGE |\n| --- | --- | --- | --- | --- | --- |\n| A. |  |  | MO DAY YEAR\u003Cbr>| MO DAY YEAR\u003Cbr>| $\u003Cbr>. |\n| B. |  |  | | | $\u003Cbr>. |\n| C. |  |  | | | $\u003Cbr>. |\n| D. |  |  | | | $\u003Cbr>. |\n\n16. LIST BELOW ONLY THOSE CHARGES BEING CLAIMED AND ATTACH ORIGINAL ITEMIZED BILLS FROM THE PROVIDERS FOR THESE SERVICES  \nNAME(S) OF PROVIDER(S) DESCRIPTION(S) OF SERVICE(S)  \nDIAGNOSIS (IF MORE THAN ONE)  \nFROM DATE  \n17.  \n$  \n.  \n18. THIS CLAIM FORM MUST BE SIGNED.  \nIF NOT, IT WILL BE RETURNED.  \nI request benefits for these expenses and certify that the above information is correct and that the foregoing expenses were incurred for the above named patient. I authorize any physician, nurse, hospital or other providers or suppliers in possession of information concerning the patient to furnish such information to CareFirst BlueCross BlueShield upon request.  \nMO DAY YEAR  \nSubscriber Signature Date  \nAny person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insuranc","cbCaijM1wmDEsPby","https://ap.wps.com/l/cbCaijM1wmDEsPby","pdf",126469,"English","# Form Instructions\n## Complete Separately for Each Family Member\n## Items 1–18: Required Information\n## Attach Original Itemized Bills and Sign\n## Authorization for Assignment of Benefits","[{\"question\":\"每位家庭成员是否需要单独填写一份表单？\",\"answer\":\"需要。表单要求为每位家庭成员单独填写一份单独的理赔表。\"},{\"question\":\"提交理赔时必须附哪些材料？\",\"answer\":\"需要附提供服务方出具的原始逐项账单（itemized bills），并确保账单包含抬头信息、患者姓名、每项服务日期、每项服务收费与服务描述等要素。\"},{\"question\":\"表单是否必须签名？未签名会怎样？\",\"answer\":\"必须签名。若未签名，理赔表将被退回。\"},{\"question\":\"若患者有其他健康保险或属于Medicare覆盖范围，需要填写哪些内容？\",\"answer\":\"需要在相应条目中选择并填写：是否有其他健康保险、其他保险公司的名称；以及是否属于Medicare覆盖（含Part A/Part B及Medicare HIC number）。\"}]","Health Benefits Claim Form | PDF",1789633521]