Transcription of International Claim Form
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Example: dental hygienist
International Claim Form
1. Patient Information 1A. Member IDInclude all letters and numbers as shown on your Blue Cross Blue Shield identification card 1B. Patient s name (First, middle initial, last) 1C. Patient s date of birth 1D. Patient s sexMM/DD/YYYY Male Female1E. Name of subscriber (First, middle initial, last) 1F. Subscriber s date of birth 1G. Patient s relationship to subscriberMM/DD/YYYYSelf Spouse Child1H. Subscriber s current mailing address (Street, city, state, and country or ZIP code) 1I.
General Information • The Blue Cross Blue Shield Global ® Core International Claim Form is to be used to submit institutional and professional claims for
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