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How to use or fill out Member forms - Arkansas Blue Cross and Blue Shield
- Click ‘Get Form’ to open it in the editor.
- Begin by entering your Enrollee ID and Group Number, which can be found on your Arkansas Blue Cross and Blue Shield ID card.
- Fill in your personal information including Last Name, First Name, Street Address, City, State, ZIP code, Date of Birth, and Sex.
- Indicate if you have Other Health Insurance by selecting 'Yes' or 'No'. If applicable, provide the name and policy number of the other insurance.
- Enter the Provider Name and their NPI/TIN. Specify the Date of Service and select the Procedure Description from options like Cleaning, Oral Exam, or X-ray.
- Review all entered information for accuracy. Remember to complete one form for each enrollee and ensure you have original itemized bills ready for submission.
- Sign and date the form at the bottom to certify that all information is true and accurate before mailing it to the specified address.
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See more Member forms - Arkansas Blue Cross and Blue Shield versions
| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2019 | 4.8 Satisfied (37 Votes) |
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