Blue Shield of California Subscriber's Statement of Claim 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the subscriber's name and mailing address. Ensure all fields are completed accurately.
3. Indicate whether the service is an out-of-network self-referral by selecting 'Yes' or 'No'.
4. Provide the patient's details, including their name, date of birth, and relationship to the subscriber.
5. Describe the patient's illness or injury briefly, specifying if it was due to an injury, illness, or pregnancy.
6. If applicable, indicate any other health coverage and provide details such as policy ID number and insuring company information.
7. Complete sections regarding Medicare coverage if relevant, including effective dates for Parts A and B.
8. Finally, sign and date the form to certify that all information provided is accurate before submitting it.

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