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Subscribers Statement of Claim 2026
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- Click ‘Get Form’ to open the Subscribers Statement of Claim in our editor.
- Begin by filling in the Subscriber's name, number, and mailing address. Ensure all details are accurate to avoid delays.
- Indicate if the address is new by checking 'Yes' or 'No'. Then, provide the date of birth and select the gender.
- Specify your relationship to the subscriber (Self, Spouse, Child) and briefly describe the patient's illness or injury.
- Fill in details regarding treatment type (Injury, Illness, Pregnancy) and relevant dates. If applicable, indicate if the patient is retired.
- If there is other health coverage, check 'Yes' and provide policy ID number and insuring company details.
- Complete employment-related questions and Medicare information if applicable. Finally, sign and date the form in the designated area.
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This form is to be used ONLY when the Provider of Service does not submit your claim directly to Blue Shield.
Submit a claim only when you are billed for services. Submit a separate form for each patient. 3. Attach an original itemized bill. Mail claim form and all