Please see the instructions on the reverse side of this form before co m pleting 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1: Patient Information. Fill in your Alpha prefix Identification number from your Blue Cross Blue Shield card, followed by the patient's name, date of birth, and sex.
3. Continue to provide details about the subscriber, including their name, date of birth, and mailing address. Ensure all fields are completed accurately.
4. In Section 2: Other Health Insurance, indicate if the patient has other coverage. If yes, complete all relevant fields regarding the other insurance provider.
5. For Section 3: Diagnosis, describe the illness or injury and specify if it was work-related. Include any necessary details about accidents.
6. In Section 4: Charges, list each service provided along with itemized bills attached for verification.
7. Complete Section 5: Payee by selecting your payment preference and providing necessary banking information if applicable.
8. Finally, sign and date the form in Section 6 to certify that all information is correct before submitting it through our platform.

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