Home Claims Form CL-438 Medical Expense Claim

Form CL-438 Medical Expense Claim

Form CL-438 Medical Expense Claim

 

INSTRUCTIONS: ALABAMA MEDICAL EXPENSE CLAIM (Form CL-438)

 

 

Alabama public employees enrolled in a program administered by BlueCross BlueShield use form CL-348 to file a medical expense claim. This document can be obtained from the website maintained by BlueCross BlueShield of Alabama.

 

Alabama Medical Expense Claim CL-438 Step 1: In box 1, enter the patient's last name, first name and middle initial.

 

Alabama Medical Expense Claim CL-438 Step 2: In box 2, enter your contract number as it appears on your ID card.  If applicable, include any letters.

 

Alabama Medical Expense Claim CL-438 Step 3: In box 3, enter your group number as it appears on your ID card or your place of employment.

 

Alabama Medical Expense Claim CL-438 Step 4: In box 4, enter the patient's date of birth.

 

Alabama Medical Expense Claim CL-438 Step 5: In box 5, indicate the patient's gender by checking "Male" or "Female" as applicable.

 

Alabama Medical Expense Claim CL-438 Step 6: In box 6, indicate the patient's relationship to the contract holder by checking "Self," "Child," "Spouse" or "Other" as applicable. If the latter, provide an explanation.

 

Alabama Medical Expense Claim CL-438 Step 7: On the first line of box 7, enter the contract holder's last name, first name and middle initial.

 

Alabama Medical Expense Claim CL-438 Step 8: On the second line of box 7, enter the contract holder's street address.

 

Alabama Medical Expense Claim CL-438 Step 9: On the third line of box 7, enter the contract holder's city, state, zip code and daytime telephone number, including any extension if applicable.

 

Alabama Medical Expense Claim CL-438 Step 10: In section 8, indicate whether the patient is covered under any other group health insurance plan with a check mark. If yes, enter the name of the policy holder on the first blank line, the name and address of the insuring company on the second blank line and the I.D. number on the third blank line. Answer all questions in this section concerning Medicare eligibility as instructed.

 

Alabama Medical Expense Claim CL-438 Step 11: Section 9 concerns the cause of the condition. Answer lines 9a through 9c by checking any applicable statements.

 

Alabama Medical Expense Claim CL-438 Step 12: Enter the diagnoses in Section 10.

 

Alabama Medical Expense Claim CL-438 Step 13: Enter the name, telephone number of the ordering physician in Section 11. Sign and date the bottom of the page.

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