/ Empire
Blue Cross
Blue Shield / SUBSCRIBER INPATIENT
CLAIM / CLAIM NUMBER

DO NOT WRITE IN THIS AREA

622 Third Avenue, New York, N.Y.10017

SUBSCRIBER SECTION

/

TO BE COMPLETED BY SUBSCRIBER – SEE INSTRUCTIONS ON REVERSE SIDE

  1. PATIENT’S LAST NAME
/ FIRST NAME /
  1. IDENTIFICATION NO. (AND PREFIX , IF ANY)
/ SUFFIX OR DEPT/DIV NO.
3.PATIENT’S STREET ADDRESS CITY AND STATE / ZIP CODE /
  1. IN CARE OF NAME (c/o)

5.PATIENT’S BIRTHDATE / 6.AGE / 7.SEX
Male Female
1 2 / 8.PATIENT’S RELATIONSHIP TO SUBSCRIBER
SELF SPOUSE CHILD OTHER (EXPLAIN) / 9.PATIENT’S EMPLOYER (IF FULL TIME COLLEGE STUDENT, GIVEN NAME OF SCHOOL AND CHECK BOX)
MO. / DAY / YR.
10. SUBSCRIBER’S LAST NAME, CHECK BOX IF SAME AS PATIENT’S SAME / FIRST NAME, CHECK BOX IF SAME AS PATIENT’S
SAME / 11.SUBSCRIBER’S EMPLOYER
12.PATIENT’S HOSPITAL ACCOUNT NUMBER / 13.HOSPITAL NAME / 14.
15. HOSPITAL STREET ADDRESS / CITY AND STATE / (COUNTRY) / ZIP CODE
16.DATE ADMITTED / 17.DESCRIBE ILLNESS FOR WHICH PATIENT WAS HOSPITALIZED
MO. / DAY / YR.
18.DATE DISCHARGED / 19.IS PATIENT COVERED BY MEDICARE?
YES NO IF YES ATTACH
1 2 EXPLANATION OF BENEFITS / 20. CHECK BOX IF INJURY
RESULTED FROM
MOTOR VEHICLE ACCIDENT / 21.IS INJURY JOB RELATED?
YES NO
MO. / DAY / YR.
22.IS PATIENT COVERED UNDER ANOTHER HEALTH INSURANCE GROUP PLAN?
YES NO IF YES, NAME OF INSURER
23.TOTAL HOSPITAL CHARGES (INDICATE CURRENCY FOREIGN OR US$) / HOW MUCH DID THE PATIENT PAY? (ATTACH RECEIPT OR PROOF OF PAYMENT) / HOW MUCH WAS PAID BY THE GOVERNMENT HEALTH PLAN?
CHECK IF YOU WISH PAYMENT TO BE
SENT TO THE HOSPITAL / 24.SIGNATURE / DATE SIGNED

DO NOT WRITE BELOW THIS LINE – FOR EMPIRE BLUE CROSS AND BLUE SHIELD USE ONLY

GROUP EMPIRE BLUECROSS AND BLUE SHIELD SECTION / FOREIGN CURRENCY CONVERSION / CENT
CERT
TYPE
DIAG
BILLING CODE / NY/PA
SERVICE
CODE / SURGICAL
MATERNITY
MEDICAL
OTHER / 236 / CLASSIFICATION CODES
COUNTRY / DATE OF EXCHANGE / OWNSHP / GOVERNMENT
NON-GOVERNMENT
N/A
OTHER / 1
2
99
RATE OF EXCHANGE / SOURCE
B P / FEP
DIAGNOSIS
CODE / MAT NORM
TM/TS
MED
ACCIDENT
MAT.COMP
OTHER / 12345
SERVICES / FOREIGN CURRENCY / U.S. DOLLARS / SERVICE
ACCREDT
AFFILIATION / GENERAL
NON-GEN-PSYCHE
NON-GEN-ALCOHOL
NON-GEN-TB
NON-GEN-REHAB
NON-GEN-OTHER
SUPPLY AGENCY
RENTAL AGENCY
FREE STAND-CLIN-HEMO
FREE STAND-CLIN-PSY
HEMODYALYSIS HOSP
N/A
OTHER
ACC-NON-ECF
NON-ACC NON-ECF
MEDICARE APP-ECF
NON-MEDICARE APP ECF
N/A
OTHER
MEMBER EMPIRE BLUE CROSS AND
BLUE SHIELD
CITY
CO-OP
FOREIGN
NON-MEM IN AREA
ECF WITH BLUE CROSS PLAN
AGREEMENT
ECF WITHOUT BLUE CROSS PLAN
AGREEMENT
MEMBER ANOTHER PLAN
NON-MEM APPRV
NON-MEM QUALIFY
N/A
OTHER / 11
12
13
14
15
16
17
18
19
20
21
99
31
32
33
34
99
50
51
52
53
54
55
56
57
58
59
99
FULL / DISC / FULL / DISC
ROOM
AND
BOARD / HOSP DAYS
ANCILLARY
SERVICES / 1
2
NON-PLAN / 3
TOTALS / REGULAR UNBILLED
REGULAR BILLED
MEDICARE DEDUCTIBLE
MEDICARE CO-INSURANCE
MEDICARE D AND C
COMBO OTHER THAN ‘T’
MEDICARE LIFETIME
MEDICARE SERV. BENEFITS
SC ECP OR FOREIGN
MEDICARE NO LIABILITY
OTHER / UBDCTXLSEY
PROF
FEES / SPEC
NURSES / TOTAL HOSPITAL BILL
$
REMARKS
MANUAL REVIEW YES / 1
ELIGIBLE ‘R’ PROCEDURE
BY PASS ‘X’ PROCEDURE / 1
2
SOURCE SET UP IN HOUSE
CON ED
CODE OTHER / 23
COB YES / 1
MULT. COV YES / 1
SCREENER / MED. EXAM / CODER

FOR SELF CERTIFICATION GROUP USE ONLY

TYPE OF CONTRACT
INDIVIDUAL
FAMILY / EFFECTIVE DATE
MO DAY YR / GROUP NO. / GROUP CONTRACT NAME / AUTHORIZED SIGNATURE AND DATE
GC
/

Empire

Blue Cross
Blue Shield

622 Third Avenue, New York, N.Y.10017

SUBSCRIBER IN-PATIENT

CLAIM FORM

Dear Subscriber:

Before completing this form, please review your hospital service contract, or your benefits booklet, to determine if coverage is available for the type of treatment rendered by the hospital. If it appears that coverage is available, please complete all the information requested in the subscriber section on the reverse side of this form and attach the receipted hospital bill showing a breakdown of charges.

When hospitalized in a foreign country, include, if possible, an English translation of the charges and services rendered, along with the hospital bill.

Do not use this form if care is rendered in a member hospital of Empire Blue Cross and Blue Shield since the hospital will automatically submit the claim to us. Our member hospitals are located in New York City, Long Island, and adjacent areas of New York Sate, New Jersey and Connecticut. When care is rendered in a member hospital, the claim must be filed by the hospital because of special payment arrangements. To accomplish this, please notify the hospital of your identification number and other related information, so that the hospital can report the claim to us.

Empire Blue Cross and Blue Shield

Note to “Self-Certification” groups:

Possible duplication of work can be eliminated by certifying the patient’s eligibility

in advance. Just complete the section marked “For Self-Certification group use only”

on the bottom of this form.