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CUSTOMER. CLAIM. FORM. INSURED AND PATIENT INFORMATION – ALL SECTIONS MUST BE COMPLETED. Insured's Name (as shown on ID card). Medical Claim Form. Read instructions on reverse side. Mail to: Anthem Blue Cross and Blue Shield. PO Box 105187. Atlanta, GA 30348. 00361CEMENABS Visit Anthem Blue Cross for group health insurance plans in California. Anthem Blue Cross : Member Claim Forms. Member Claim Forms. Medical Claim Form. All forms are available in Portable Document Format (PDF). Instructions for completing each form have been included. To view the forms, you may need to Medical Claim Form. 24066CEMENABS Rev. 10/12. SECTION 1: PATIENT INFORMATION. Last name. First name. M.I.. Does the patient have other health Your cooperation in completing all items on the claim form and attaching all required Section B. SUBSCRIBER INFORMATION (on Anthem Blue Cross card). Visit Anthem Blue Cross Blue Shield for group health insurance plans. International Claim Form · Health Insurance Claim Form You are not bothered with claim forms and we often need more details than are ordinarily provided on bills to patients. Sometimes, a physician may not bill us or Claim Form. 26005MEMENABS 11/11. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Your cooperation in completing all items on the claim form and attaching all Anthem Blue Cross Plan by the provider of service (the physician, clinical,
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