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CMS-1500 Form for BlueCard - Dgaplans.org - dgaplans-2026
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How to use or fill out CMS-1500 Form for BlueCard - Dgaplans.org - dgaplans
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- Click ‘Get Form’ to open it in the editor.
- In Box 1a, enter your Insured’s I.D. Number exactly as it appears on your Health Plan ID card, including the prefix 'DGA' and suffix 'J'.
- For Box 2, input the Patient’s Name as it appears on the Health Plan ID card. If a dependent child is involved, use their name as recorded with the Health Plan.
- In Box 4, write the Insured’s Name. If the insured is also the patient, ensure both names are identical; avoid using terms like 'self' or 'same'.
- Fill in Box 7 with the Insured’s Address exactly as listed with the Health Plan.
- Complete Box 11 by entering the Group Number starting with '276945' from your Health Plan ID card.
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