Empire Blue Cross Claim Form PDF Details

If you are a policyholder of Empire Blue Cross, you may be eligible to receive benefits for medical expenses. In order to process your claim, you will need to complete and submit a claim form. The form can be downloaded from the Empire Blue Cross website, or you can request one from the company by mail or phone. The completed form should be submitted as soon as possible after the expense has been incurred. Failure to do so may result in denial of your claim.

QuestionAnswer
Form NameEmpire Blue Cross Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesphy tww blue template, empire hcfa blue shield, tww claim blue cross, empire bcbs claim form

Form Preview Example

APPROVED OMB-0938-0008

 

 

PO BOX 5072

 

 

 

 

 

 

MIDDLETOWN, NY 10940-9072

 

 

 

ATTN: CLAIM SET-UP

 

 

 

FOR CUSTOMER SERVICE: 1-800-409-1620

Note: Important filing instructions

 

 

 

 

 

PICA

HEALTH INSURANCE CLAIM FORM

on next page.

CARRIER

PICA

1. MEDICARE

 

 

MEDICAID

 

 

CHAMPUS

 

 

CHAMPVA

 

 

 

GROUP

 

 

 

FECA

 

 

 

OTHER

1a. INSURED’S ID NUMBER

 

 

 

 

 

 

(FOR PROGRAM IN ITEM 1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEALTH PLAN

 

 

BLK LUNG

 

 

TWWAOL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Medicare #)

 

 

(Medicaid #)

(Sponsor’s SSN)

 

 

(VA File #)

 

 

X (SSN or ID)

 

 

 

(SSN)

 

 

 

(ID)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. PATIENT’S NAME (Last Name, First Name, Middle Initial)

 

 

 

 

3. PATIENT’S BIRTH DATE

 

 

 

 

 

 

 

 

 

 

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

 

DD

 

 

YY

 

 

 

SEX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. PATIENT’S ADDRESS (No. and Street)

 

 

 

 

 

 

 

 

 

6. PATIENT RELATIONSHIP TO INSURED

7. INSURED’S ADDRESS (No. and Street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self

 

Spouse

 

 

Child

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE

 

8. PATIENT STATUS

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single

 

 

Married

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP CODE

 

 

 

 

 

TELEPHONE (Include Area Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP CODE

 

 

 

 

 

 

TELEPHONE (Include Area Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employed

Full-Time

Part-Time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Student

Student

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

 

10. IS PATIENT’S CONDITION RELATED TO:

11. INSURED’S POLICY GROUP OR FECA NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

296541

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. OTHER INSURED’S POLICY OR GROUP NUMBER

 

 

 

 

 

 

a. EMPLOYMENT? (Current or Previous)

a. INSURED’S DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YY

 

 

 

 

 

 

 

SEX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

F

b. OTHER INSURED’S DATE OF BIRTH

 

 

 

 

 

 

 

 

 

b. AUTO ACCIDENT?

 

 

 

PLACE (State)

b. EMPLOYER’S NAME OR SCHOOL NAME

 

 

 

 

 

 

MM

DD

 

YY

 

 

M

SEX

 

F

 

 

 

 

 

 

 

 

 

 

YES

 

 

 

NO

 

 

 

 

 

 

 

AOLTIME WARNER, INC.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. EMPLOYER’S NAME OR SCHOOL NAME

 

 

 

 

 

 

 

 

c. OTHER ACCIDENT?

 

 

 

 

 

 

 

 

 

 

c. INSURANCE PLAN NAME OR PROGRAM NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

 

NO

 

PPO PLAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. INSURANCE PLAN NAME OR PROGRAM NAME

 

 

 

 

 

 

d. RESERVED FOR LOCAL USE

 

 

 

 

 

 

 

d. IS THERE ANOTHER NAME OR BENEFIT PLAN?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

If YES, return to and complete item 9a–d.

 

 

 

 

 

 

 

READ BACK OF FORM BEFORE COMPLETING THIS SECTION.

 

 

 

 

 

 

 

 

 

 

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment

12. I AUTHORIZE THE RELEASE OF INFORMATION AS DESCRIBED ON THE REVERSE SIDE OF THIS CLAIM FORM.

 

of medical benefits to the undersigned physician or supplier for services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

described below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOT APPLICABLE

 

 

 

 

 

 

SIGNED _____________________________________________________________

DATE ________________________________

 

SIGNED ___________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. DATE OF CURRENT:

ILLNESS (First symptom) OR

 

 

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

MM

DD

 

 

YY

INJURY (Accident) OR

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YY

 

 

MM

DD

YY

 

 

 

 

 

 

MM

 

DD

 

YY

 

 

 

 

 

 

 

 

PREGNANCY (LMP)

 

 

 

 

 

GIVE FIRST DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

 

 

 

 

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE

 

 

17a. ID NUMBER OF REFERRING PHYSICIAN

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YY

 

 

 

 

 

 

MM

 

DD

 

YY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

 

 

 

 

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19. RESERVED FOR LOCAL USE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. OUTSIDE LAB?

 

 

 

 

 

 

 

$ CHARGES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (RELATE ITEMS 1, 2, 3 OR 4 TO ITEM 24E BY LINE)

 

 

 

 

 

 

 

 

22. MEDICAID RESUBMISSION

 

 

ORIGINAL REF. NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23. PRIOR AUTHORIZATION NUMBER

 

 

 

 

 

 

 

2.

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24.

 

A

 

 

 

 

 

 

 

B

 

 

C

 

 

 

 

 

 

 

D

 

 

 

 

 

 

 

 

E

 

 

F

 

 

G

 

 

H

I

J

 

 

 

 

K

 

 

DATE(S) OF SERVICE

 

PLACE

 

TYPE

PROCEDURES, SERVICES OR SUPPLIES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DAYS

 

EPSDT

 

 

 

 

 

 

 

 

 

FROM

 

 

 

 

TO

 

OF

 

OF

 

(EXPLAIN UNUSUAL CIRCUMSTANCES)

 

DIAGNOSIS

 

 

$ CHARGES

 

 

OR

 

FAMILY

EMG

COB

 

 

RESERVED FOR

MM

DD

YY

 

MM

DD

YY

SERVICE

SERVICE

 

CPT/HCPCS

 

 

MODIFIER

 

 

 

CODE

 

 

 

 

 

UNITS

 

PLAN

 

 

 

 

 

LOCAL USE

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25. FEDERAL TAX ID NUMBER

 

 

SSN

EIN

 

26. PATIENT’S ACCOUNT NO.

 

 

27. ACCEPT ASSIGNMENT?

28. TOTAL CHARGE

 

 

 

 

29. AMOUNT PAID

 

30. BALANCE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

$

 

 

 

 

 

 

$

 

 

 

 

 

 

$

 

 

31. SIGNATURE OF PHYSICIAN OR SUPPLIER,

 

 

 

32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE

33. PHYSICIANS, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE

INCLUDING DEGREES OR CREDENTIALS

 

 

 

RENDERED (If other than home or office)

 

 

 

 

 

 

 

 

 

 

 

AND PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

I CERTIFY THAT THE CARE, SERVICES AND SUPPLIES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ENTERED ON THIS FORM HAVE BEEN RENDERED TO THE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT, AND THAT I AM ENTITLED TO REIMBURSEMENT OF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THE CHARGES INDICATED.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNED

 

 

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PIN#

 

 

 

 

 

 

 

GRP#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)

 

 

 

 

 

 

 

PLEASE PRINT OR TYPE

 

 

 

 

 

 

 

 

 

 

FORM HCFA-1500 (12-90)

 

 

Services provided by Empire HealthChoice Assurance, Inc., a licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

 

 

 

 

 

 

FORM OWCP-1500

PHY 0744E-TWW 11/06

 

 

 

 

 

 

 

 

 

 

 

PATIENT AND INSURED INFORMATION

PHYSICIAN SUPPLIER INFORMATION

FILING INSTRUCTIONS

Members: You are required to complete this claim form if you receive services from a nonparticipating physician (any physician that is “out-of-network”).

1.Complete the patient and insured information sections (Boxes 1–12).

•Please make sure the three-letter alpha prefix, along with the insured’s member identification number, appears in Box 1a. Do not complete Box 13.

2.Attach the original itemized bill from the physician to the claim form and mail it to the address listed on the front of the form.

OR

Have the physician complete the physician supplier information sections (Boxes 14–33). And mail it to the address listed on the front of the form.

NOTE: If you receive services from a participating physician (an “in-network” physician), you are not required to complete any claim forms. All participating network physicians submit claims directly to their local Blue Cross and/or Blue Shield plan.

If you have any questions about completing this claim form, please call the Customer Service telephone number listed on the front of the form or the number on the back of your member identification card.

PROVIDERS: If you have rendered services to a member, please complete the physician supplier information sections (Boxes 14–33). Then mail it to the address listed on the front of the form.

PATIENT’S SIGNATURE

The patient must sign the claim form, authorizing the release of information to Empire or its designee as described below. If the patient is a minor, the signature must be that of the patient’s parent or legal guardian.

I authorize any healthcare provider, payor of health claims or government agency to furnish to Empire or its designee all records pertaining to medical history, services rendered, or payments made regarding me or my dependents for review and evaluation of any claim or services.

I authorize Empire or its designee to disclose such information to another payor or self-insurer. If my coverage is under a group contract held by an employer, association, trust fund, union or similar entity, this authorization also permits disclosure to them for purposes of utilization review or financial audit.

This authorization shall become effective immediately, and shall remain in effect until the latest of six years after the termination of coverage, or the last determination or payment by Empire on a claim or service under the coverage. This authorization shall be binding upon me, my dependents, my heirs, executors or administrators.

FRAUD STATEMENT

Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, may be guilty of a criminal act punishable under law and may be subject to civil penalties.

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