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44 11/2005
BLUE CROSS BLUE SHIELD OF GEORGIA/
BLUE CROSS BLUE SHIELD HEALTHCARE PLAN OF GEORGIA
Supporting Documentation – Standard Cover Sheet
Original Claim Number:
Claim Identification Information:
Patient First Name:
Patient Last Name:
Patient Date of Birth:
Date(s) of Service:
Provider of Service:
Tax ID#:
Subscriber/Member ID# with prefix and suffix:
Subscriber’s First Name:
Subscriber’s Last Name:
Provider Contact Person
Name:
Contact – Phone Number:
Comments (Optional):
Identify the documentation that you have attached.
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