Maine Health

Blue Cross Changes

If insurance information was not available at the time of service, please provide the following information as it appears on your insurance card(s).

Please fill out the form completely and accurately. Thank you.

First name:

Last name:

Email:

Birth Date:

Invoice Number:

Date of Service:

Blue Cross Certification #:

Group #:

Subscriber name:

Subscriber Phone:

Subscriber Employer name:

Subscriber Employer Address:

Subscriber Employer City:

Subscriber Employer State:

Subscriber Employer Zip:

Subscriber Relation:
Self
Spouse
Son
Daughter
Other

Blue Cross Coverage Effective Date:

Comments: