Bellevue Medical Claim Form PDF Details

The Bellevue Medical Claim Form is a document that provides insurance companies or other third-party payers with information on the diagnosis, treatment and services provided to an individual. The form is completed by a provider who has examined a patient and can be submitted electronically through the use of EDI (Electronic Data Interchange). It must include the date of service, medical claim number, name of insured, diagnosis codes from ICD-10 CM (International Classification for Diseases) 9th edition codes. A Bellevue Medical Claim Form can be used as evidence in court cases where malpractice occurs. These forms are also necessary when submitting claims for reimbursement from health insurance carriers such as Medicaid or Medicare.

You'll find it beneficial to know how much time you will need to prepare this bellevue medical claim form and how long the form is.

Form NameBellevue Medical Claim Form
Form Length1 pages
Fillable fields33
Avg. time to fill out6 min 51 sec

Form Preview Example

City of Bellevue LEOFF 1 Disability Board Medical Claim Form

LEOFF 1 Active/Retiree Information:

Name: ____________________________________________

Date of Birth:__________________________


SSN#: XXX-XX- __ __ __ __


State:_______ ZIP Code:_______________

Telephone Number:_________________________________


If claim is approved, check should be made payable and mailed to: _____________________________________


Reimbursement Request Information:

Service Date


Service Received

Medical Reason

Uncovered Cost

Total: $______________



Claimants Signature

Date Submitted

*Submission to the Disability Board must include the following:

Completed Disability Board Medical Claim Form.

Itemized statement from the service provider indicating any insurance payments or other payments made to the provider.

Insurance Carrier’s “Explanation of Benefits” (EOB) form and Medicare Statement for any claim submitted by a member covered by Medicare.

Provider Billing invoice if not covered by Insurance. Please provide explanation as to why this is a medical necessity (Medical Necessity is determined by the City of Bellevue Disability Board).

Submit this form with applicable receipts, statements and “Explanation of Benefits” (EOB) to:

City of Bellevue LEOFF 1 Disability Board

Human Resources

PO BOX 90012

Bellevue WA 98009-9012

Phone: 425-452-7198

H:\Retirement Services\Disability Board\Forms\2006 gmd

How to Edit Bellevue Medical Claim Form Online for Free

This PDF editor was developed to be as easy as possible. When you stick to the following actions, the procedure for preparing the DEPS file will be convenient.

Step 1: First of all, select the orange "Get form now" button.

Step 2: Now you are on the document editing page. You can edit, add content, highlight particular words or phrases, place crosses or checks, and put images.

If you want to fill in the template, type in the details the application will request you to for each of the appropriate areas:

entering details in Healthcare step 1

Please fill out the Service, Received Uncovered, Cost Provider, Total, City, of, Bellevue, LE, OFF, Disability, Board and Human, Resources field with the necessary data.

Healthcare ServiceReceived, UncoveredCost, Provider, Total, CityofBellevueLEOFFDisabilityBoard, and HumanResources fields to fill out

You will be asked for some valuable information if you want to complete the Phone section.

stage 3 to filling out Healthcare

Step 3: Click "Done". Now you may export the PDF form.

Step 4: Attempt to create as many copies of your file as possible to prevent future issues.

Watch Bellevue Medical Claim Form Video Instruction

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