BCHP Dental Reimbursement Form - bluechoicesc.com · asistans ak enfòmasyon nan lang ou pale a,...
Transcript of BCHP Dental Reimbursement Form - bluechoicesc.com · asistans ak enfòmasyon nan lang ou pale a,...
![Page 1: BCHP Dental Reimbursement Form - bluechoicesc.com · asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon entèprèt, rele nan 1-844-398-6232.](https://reader033.fdocuments.in/reader033/viewer/2022042214/5ebacf589378b015327b4b22/html5/thumbnails/1.jpg)
Please submit a bill or receipt with the provider’s name and address.
Dental Reimbursement Form
Patient’s Name: Sex: M Male M Female
Patient’s Birthdate: _____/_____/_____ MM DD YY
Patient’s Relationship to Insured: M Self M Spouse M Child M Other
Insured’s Name:
Insured’s ID Number:
Patient’s Address (No., Street):
City: State:
ZIP Code: Telephone: ( )
MM
Date(s) of Service From:
DD YY MM To: DD YY Description of Item or Service
Amount Paid
Procedure Code
Provider’s Name:
Provider’s Address (No., Street):
City: State:
( )ZIP Code: Telephone:
Please submit a bill or receipt with the provider’s name and address. Include a complete description of services provided.
Claims Address: BlueChoice HealthPlan Claims DepartmentP.O. Box 6170
Columbia, SC 29260-6170
99835-3-2018
You have 3 months from the date of service to submit this form.
![Page 2: BCHP Dental Reimbursement Form - bluechoicesc.com · asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon entèprèt, rele nan 1-844-398-6232.](https://reader033.fdocuments.in/reader033/viewer/2022042214/5ebacf589378b015327b4b22/html5/thumbnails/2.jpg)
3/[Type here] [Type here] [Type here]
Rvs 3/13/2017 1 19199-‐3-‐2017
![Page 3: BCHP Dental Reimbursement Form - bluechoicesc.com · asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon entèprèt, rele nan 1-844-398-6232.](https://reader033.fdocuments.in/reader033/viewer/2022042214/5ebacf589378b015327b4b22/html5/thumbnails/3.jpg)
3/[Type here] [Type here] [Type here]
Rvs 3/13/2017 2 19199-‐3-‐2017