Empire bcbs form 2026

1. Click ‘Get Form’ to open the empire bcbs form in the editor.
2. Begin with Section 1: Member Information. Fill in your last name, first name, member identification number (required), group number, street address, city, state, ZIP code, and middle initial.
3. Proceed to Section 2: Patient Information. Enter the patient's last name, first name, date of birth (MMDDYYYY), sex, middle initial, and relationship to subscriber.
4. In Section 3: Diagnosis, describe the illness or injury and provide the date of accident if applicable.
5. For Section 4: Work-related injuries, indicate if it was work-related and provide employer details if yes.
6. Section 5 requires information on other group health insurance. Indicate coverage status and complete additional fields if applicable.
7. In Section 6: Medicare coverage, specify if the patient is covered by Medicare and provide effective dates as needed.
8. Finally, complete Section 7 by signing and dating the form. Ensure all required signatures are included before submission.

Start using our platform today for free to streamline your empire bcbs form completion!