Claim Form — Flu Shot Only
One patient and one provider per claim form, please.
P.O. Box 5747
See reverse side for claim filing instructions.
Denver, CO 80217-5747
PLEASE PRINT
1. Subscriber number 2. Group number 3. Patient name (last, first, initial)
4. Patient birthdate
_____/_____/_____
Month Day Year
5. Patient sex
6. Patient relationship to subscriber
7. Subscriber name (last, first, initial)
£ Male £ Female
£ Self £ Spouse £ Child £ Other

8. Subscriber address (street, city, state, ZIP)
9. Is patient covered by any other 9a. Name of policyholder
Group health benefit plan?
£ Yes £ No
If no, go to question 10
9b. Name and address of insurance company
9c. Policy number
10. Name of flu shot clinic that rendered the service
11. Date of service
12. Charge for service. Please attach a copy of
your receipt as proof of payment.
_____/_____/_____ $_________________
13. Who may we contact if we have questions?
Name ______________________________________________________
Phone number ( ) _____________________
14. I certify to the accuracy and completeness of all information reported by me on this form, and authorize the release of any medical
information necessary to process this claim.

Signature______________________________________________ Date______/______/______

Please ensure that all fields are completed in full, and that this form is signed and dated. An incomplete form may delay the processing
of your claim. Services other than flu vaccine must be submitted on a separate claim form.
For Wellpoint / Source Corp use only
Dignosis code: V04.81
Place of service code: 22
*Procedure code: ___________
90656 Flu vaccine, age 3+ years
WGS/STAR Provider Tax ID: 84-2229999
An independent licensee of the Blue Cross and Blue Shield Association.
Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc.
82160-Flu (Rev. 5/07)
® Registered marks Blue Cross and Blue Shield Association.

How to File Your Claim
Be sure to ask your provider of care if he/she bills a statement to
Required information
Anthem Blue Cross and Blue Shield. Please submit statements
Itemized Bills: Summarizing the services may help us better
only if the provider does not bill us directly. To receive benefits
understand the attachments if they are not clear. The attached
for RX, or for services by a provider who does not bill us directly,
itemized bills must include the provider name, patient’s name,
complete the claim form, attach itemized bills, proof of payment
date of service, detailed description of service, and amount
(if applicable) and mail the white copy to Anthem Blue Cross and
charged for that service. These must be valid documents from the
Blue Shield, P.O. Box 5747, Denver, Colorado 80217-5747.
provider.
Keep a duplicate copy of your itemized bills and proof of payment
as they will not be returned to you. This claim may be returned to
Helpful hints
you if all required information is not present.
• If you have questions or need assistance, contact Anthem Blue
Claim filing instructions
Cross and Blue Shield Customer Service.
• To reduce the possibility of small billings getting lost or
(Corresponds to numbered items on claim form)
separated, it would be helpful if you attach these to an 8 1/2x11
A separate claim form for each family member and each provider
piece of paper.
of care must be submitted.
• We encourage you to file claims within 90 days of the service
Item number
date. Please refer to your Benefit Certificate for specific timely
1–8 Please complete all blocks. All fields required.
filing limitations.
9-9c Appropriate responses to these questions will ensure
• File only if the provider has not.
expedient and proper handling of your claim.
Important: If the services for this claim were provided by a
10 Indicate the name of the flu clinic that rendered the service.
participating physician or hospital, the benefit payment will go to
the provider.
11 The date the flu shot was administered.
A complete description of your benefits, as well as limitations
12 Indicate the total charge for the flu shot.
and exclusions applicable thereto, is available in the Benefit
13 Name and telephone number; whoever can help us if
Certificate. Final interpretation of any and all provisions of the
additional information is required.
program is governed by the Benefit Certificate.
14 Your signature attests to the accuracy and completeness
of all information on the claim and the attachments and
authorizes the release of your medical records by the provider
to our office if necessary.