TWCC Claim Forms 90054 Pw B139855
User Manual: 90054
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Page Count: 1
PATIENT INFORMATION - Person who received services
:
NAME (last, first, MI) SEX RELATIONSHIP TO SUBSCRIBER
Mo. Day Yr.
PRIMARY MEMBER INFORMATION:
NAME (last, first, MI)
ADDRESS City State Zip Code
OTHER COVERAGE INFORMATION
:
IS THIS PATIENT COVERED BY ANY OTHER GROUP WAS CONDITION RELATED TO AN AUTOMOBILE
HEALTH CARE PLAN OR MEDICARE? ACCIDENT?
WAS CONDITION RELATED TO EMPLOYMENT?
If "YES" to either of the above questions, please complete the following:
Policyholder's Name Policy Number
Mo. Day Yr.
Insurance Company's Name Please indicate type of coverage
Anthem Blue Cross Blue Shield
Insurance Company's Address City State Zip Code
P.O. Box 54159 Los Angeles CA 90054-0159
Employer's Name Group No. Medicare No. Medicare Effective Medicare
TWCC Holding Corp. 174513 Date
MEDICAL INFORMATION:
IS THIS AN ILLNESS OR INJURY MO DAY YR
IF INJURY, DATE OF INJURY IS REQUIRED
Describe the illness or injury which required treatment:
How did the injury occur?
READ
THIS
SIGNED DATE
MEMBER NUMBER GROUP NUMBER NUMBER OF ITEMS
ATTACHED
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
DATE OF BIRTH
Any intentional false statement in this application or
willful misrepresentation relative thereto is a violation
of the law.
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.
DATE OF BIRTH
MALE
FEMALE SELF
SPOUSE CHILD
OTHER
IMPORTANT Check here if this is a new address
YES NO
YES
YES NO
NO
Health Dental Vision Drug
Part A Part B
MAIL CLAIM TO:
A
nthem Blue Cross and Blue Shield
P.O. Box 54159
Los Angeles, CA 90054-0159
MEMBER CLAIM FORM
