CMS-1500 Form for BlueCard - Dgaplans.org - dgaplans-2026

1. Click ‘Get Form’ to open it in the editor.
2. 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'.
3. 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.
4. 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'.
5. Fill in Box 7 with the Insured’s Address exactly as listed with the Health Plan.
6. Complete Box 11 by entering the Group Number starting with '276945' from your Health Plan ID card.

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