MEDICAL EXPENSE
Claim Form and Instructions
GeoBlue Student Claim Rev. 02/17
1. PATIENT INFORMATION
Member ID
Please enter Member ID as shown on card
Patient’s Name (Given Name, Family Name) Patient’s date of birth (MM/DD/YYYY) Patient’s Gender
Male Female
Name of Insured Member (Given Name, Family Name) Insured’s date of birth (MM/DD/YYYY) Patient’s Relationship to Insured
Self Spouse Child
Name of Plan Program Sponsor
Insured’s current mailing address
Member Email Member Phone Number
2. OTHER HEALTH INSURANCE
Is the patient covered under other health insurance? YES NO
If YES
, please complete this section
Name and address of other insurance company Name of the Policy Holder
Policy Holder’s Date of Birth (MM/DD/YYYY) Policy or identification number of other coverage
Effective Date
(MM/DD/YYYY)
Termination Date
(MM/DD/YYYY)
3. DIAGNOSIS – describe illness, injury or symptoms requiring treatment
IF IN AN ACCIDENT
Date of Accident (MM/DD/YYYY) Place of Accident
Date of Doctor/Hospital Visit
(MM/DD/YYYY)
Was the injury a result of participation
in an Intercollegiate Sport?
YES
NO
Was this an Auto Accident?
YES
NO
Description/Details of Injury
(attach additional notes if necessary)
IF SICKNESS/ILLNESS
Onset Date of Symptoms (MM/DD/YYY) Date of Doctor/Hospital Visit (MM/DD/YYYY)
Have you had this Sickness/Illness
before?
YES NO If YES, when was the last occurrence and/or doctor/hospital visit?
Description/Details of Illness
(attach additional notes if necessary)
4. CHARGES – use a separate line to list each type of service or provider and attach itemized bills for all services
Name, City & Country of provider making charge Diagnosis
Description of service
(Office Visit, X-ray, Prescription, etc.)
Dates of Service
(MM/DD/YYYY)
Charges
(Please indicate
currency)
5. CLAIM PAYMENT REIMBURSEMENT
Have these doctor/hospital bills been paid by
you?
YES NO
If YES, payment will be made to Primary Insured via Check (payable in US$ and
mailed to the address indicated above)
If NO, do you authorize payment to the provider
of service for medical services claimed?
YES NO
If payment is to be paid to an international provider, please ensure bank information is
on the provider invoice. See Filing Instructions for non-international provider payments
6. SIGNATURE
I certify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named above. Authorization is hereby given
to any provider of service, that participated in any way in the patient’s care, to release to GeoBlue and its business associates in any country any medical or
other personal information that they deem necessary to provide service or adjudicate this claim, recognizing that applicable law concerning personal information
may differ among countries. Please see the back of this form for important information.
Signature of Insured member or patient Date
GeoBlue Student Claim Rev. 02/17
FRAUD NOTICE
General Fraud Warning –
Any person who knowingly and with intent to defraud, submits an application or files a claim
containing a false or deceptive statement is guilty of insurance fraud.
AUTHORIZATION FOR ASSIGNMENT
Authorization for Assignment –
All payments will be made to the Primary Insured if the doctor/hospital bills have been paid by you.
If you would like a third party to receive reimbursement for covered expenses under this policy,
you must request an Authorization for Assignment from GeoBlue Member Services.
Authorization for Assignment of Benefits is voluntary. Any documentation accompanying a payment
or otherwise could contain federal and/or state Protected Health Information and other protected private
or financial information. Protected Health Information means health data that could be used to individually
identify you including your name, address and specific medical material and facts.
INSTRUCTIONS FOR FILING A CLAIM
The following steps will assist you in filing claims. Please note that submitting an incomplete form will result in the delay of processing your claim.
For Parts 1 – 4 of the claim form:
Please submit a separate claim form for each patient
Please be as descriptive as possible
Submitted bills must be itemized – canceled check, cash register receipts and non-
itemized “balance due” statements cannot be processed.
An Itemized bill is a full description of all actual charges and each itemized bill must
include:
Name and address of provider (doctor, hospital, laboratory, ambulance
service, etc.), name of patient, date(s) of service, amount charged for each
service described, diagnosis or reason for treatment
Submitted bills for Prescriptions should include the name of the drug, the quantity
dispensed and the dosage.
To accurately complete Part 5, Payment
Details:
Payments are made to the Primary
Participant/Insured Member on the
plan. Payments cannot be made
directly to a dependent or to a third
party (other than the medical provider).
If paying international provider,
invoice must include bank information
Providers in the USA, Puerto Rico and
the U.S. Virgin Islands should bill their
local Blue Cross Blue Shield Plan
directly.
SEND COMPLETED CLAIM FORMS, WRITTEN INQUIRIES AND ADDRESS CHANGES TO THE APPROPRIATE ADDRESS BELOW
CLAIMS INCURRED INSIDE
the U.S., Puerto Rico, and U.S. Virgin Islands
CLAIMS INCURRED OUTSIDE
the U.S., Puerto Rico, and U.S. Virgin Islands
GeoBlue
P.O. Box 21974 Eagan, MN 55121
Claims Submission Fax: 1.610.482.9623
Claims Submission Email: claims@geo-blue.com
GeoBlue
Claims Department
PO Box 1748
Southeastern, PA 19399-1748
Claims Submission Fax: 1.610.482.9623
Claims Submission Email: claims@geo-blue.com
24/7 Member Services: Outside the U.S.: +1.610.263.2847 Toll Free Within the U.S.: 1.844.268.2686
