TWCC Claim Forms 90054 Pw B139855

User Manual: 90054

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MAIL CLAIM TO:
Anthem Blue Cross and Blue Shield
P.O. Box 54159
Los Angeles, CA 90054-0159

MEMBER CLAIM FORM
MEMBER NUMBER

GROUP NUMBER

PATIENT INFORMATION - Person who received services:
NAME (last, first, MI)
SEX
MALE
FEMALE

NUMBER OF ITEMS
ATTACHED

RELATIONSHIP TO SUBSCRIBER
SELF
CHILD
SPOUSE
OTHER

Mo.

DATE OF BIRTH
Day
Yr.

PRIMARY MEMBER INFORMATION:
NAME (last, first, MI)
ADDRESS

City

State

Zip Code

IMPORTANT Check here if this is a new address
OTHER COVERAGE INFORMATION:
IS THIS PATIENT COVERED BY ANY OTHER GROUP
HEALTH CARE PLAN OR MEDICARE?
YES

WAS CONDITION RELATED TO AN AUTOMOBILE
ACCIDENT?
NO
YES
WAS CONDITION RELATED TO EMPLOYMENT?

NO

YES
If "YES" to either of the above questions, please complete the following:
Policyholder's Name
Mo.

DATE OF BIRTH
Day
Yr.

Insurance Company's Name
Anthem Blue Cross Blue Shield
Insurance Company's Address
P.O. Box 54159
Employer's Name
TWCC Holding Corp.

NO
Policy Number

Please indicate type of coverage
Health
City
Los Angeles
Group No.
174513

Medicare No.

Medicare Effective
Date

MEDICAL INFORMATION:
IS THIS AN ILLNESS
OR INJURY
IF INJURY, DATE OF INJURY IS REQUIRED
Describe the illness or injury which required treatment:

Dental
Vision
State
Zip Code
CA
90054-0159

Drug

Medicare
Part A

MO

Part B

DAY

YR

How did the injury occur?

PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE - I authorize the release of
any medical information necessary to process this claim and also certify that the
above information is correct.
SIGNED

READ
THIS

Any intentional false statement in this application or
willful misrepresentation relative thereto is a violation
of the law.
DATE

NOTE - Please indicate the physician providing service on each bill.
If you have questions or need any assistance, please call the number listed on your Member ID card
Independent Licensee of the Blue Cross Blue Shield Association
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