Claim forms and claims-related forms.
This form authorizes Horizon BCBS to obtain any and all medical records and information from providers of service and/or hospitals, relating to the subscriber and eligible dependents, to the extent required to administer the Plan.
ID: 3247 (W0312)
ID: ID 3200 (w1106)
When you are submitting expenses for more than one family member, please use a separate claim form for each person. It is suggested that you make copies for your own use before you submit the original bills.
ID: 7190 (0319)
ID: 9429 (W0718)