Blue Cross Health Insurance Claim Form

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Download the form below to fill-in and submit a claim to Blue Cross Health Insurance.

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

The participant authorizes any health care provider, payor of health claims, or government agency to furnish to Empire or its designee all records pertaining to medical history, services rendered, and payments made regarding the participant or the participant's dependents for review and evaluation of any claim or services.

The participant authorizes Empire or its designee to disclose such information to another payor or self-insurer. If the participant's 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 the participant, the participant's dependents, heirs, executors or administrators.

Completed claim forms, together with any other pertinent attachments, should be sent to:

Empire Blue Cross Blue Shield
PO BOX 1407, Church Street Station
New York, N.Y. 10008-1407

 

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