Medical Claim Form - Excellus BlueCross BlueShield 2026

1. Click ‘Get Form’ to open the Medical Claim Form in the editor.
2. Begin by entering your Excellus Medicare ID# at the top of the form, which can be found on your ID card.
3. Fill in your personal information, including your last name, first name, street address, city, state, and ZIP code.
4. Provide your date of birth in the specified format (MM/DD/YYYY) and indicate whether the submitted expenses are related to a motor vehicle or work-related accident.
5. If you have other health insurance, check 'Yes' and provide the name of the other insurance company along with your policy number.
6. Sign and date the form to certify that all information is accurate. Ensure you include a phone number for contact purposes.
7. Attach original itemized receipts that meet all requirements outlined in the form before submitting it to Excellus BlueCross BlueShield.

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