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Master Medical Claim - How to Complete the Form

Please: Separate receipts, forms and vouchers for each individual. Complete a separate claim form for each member. Staple or paper clip receipts to the appropriate claim form. Please do not glue or tape. If applicable, attach a copy of your Explanation of Medicare Benefits form or Medicare voucher.


If another insurance carrier has made a payment on the claim, please include the statement showing what was paid.

Save copies of all items for your records.
Master Medical Claim

Item Instruction
1-2 Enter the subscriber's (i.e. card holder's) name as it appears on their BCBSM identification card.
3 Enter your mailing address.
4-5 Copy these numbers from your ID card.
6-12 Patient information: Fill in information on the person who received services or supplies. Do not use nicknames such as Suzie or Donnie. Please use full given name, such as Susan or Donald.
13-24 Do you have other health care coverage? If so, please include the following information: Name of other company and spouse's date of birth.
15 Remember that the subscriber must sign and date the claim form.