026565 (01-2013) Premera Blue Cross Blue Shield of Alaska is an Independent Licensee of the Premera Blue Cross Blue Shield Association

Medical Travel Support Claim Form Use this form for travel claims you have through the Medical Travel Support program. Do not use this form for medical, vision, dental, and other travel claims, or for prescription reimbursement. (See instructions on back.) 1. PATIENT / MEMBER Prefix and ID number (see ID card)

Group number (see ID card)

Patient name (first, middle, last)

Date of birth (month/day/year)

Address City State Zip

Home phone number Work or alternate phone number Subscriber name (first, middle, last)

2. PROCEDURE / FACILITY/AUTHORIZATION ACL Repair by Arthroscopy Bariatric Surgery (Lap Band) Breast Lumpectomy Cardiac Angioplasty – with or without stent placement Coronary Bypass (CBG) Hip Replacement Hysterectomy Knee Arthroscopy with Cartilage Repair Knee Replacement

Laminectomy Laparoscopic Gall Bladder Removal Left Heart Catheterization Lithotripsy – Fragmenting of Kidney Stones Partial or Total Removal of Thyroid Gland Removal of Prostate Gland & Surrounding Tissue Shoulder Arthroscopy Spinal Fusion

Facility Evergreen Hospital Overlake Medical Center Providence Alaska Providence Everett Swedish Hospital Valley Medical Center Virginia Mason Other

Ambulatory (Outpatient) Surgical Center Bellevue Urology Surgery Center Bel-Red Ambulatory Surgical Center Eastside Urology Associates Evergreen Surgical Center First Hill Surgery Center Hand & Wrist Surgery Center of WA Minor & James Medical North Seattle Surgery Center Northwest Nasal Sinus Center Orthopedics International Overlake Surgery Center Pacific NW Facial Plastic Surgery Polyclinic Surgical Seattle Facial Plastic Surgery Center Seattle Hand Surgery Group Washington Institute Surgery Center Other

Other Facility or Ambulatory Surgical Center Name

City

State Zip Reference Number #

3. CLAIM DETAILS Date of medical procedure

Trip duration (length of stay) From:________________________ To:________________________

Travel Expenses

Traveler Airfare Lodging Car Rental Taxi Parking Ferry Mileage ($.23/mile) Other

Member

Companion

Other

4. SIGNATURE Complete this form in full, sign it, and include all of the required documents so we can process your claim quickly. Mail to: Premera Blue Cross Blue Shield of Alaska, P.O. Box 240609, Anchorage, AK 99524-0609. Patient signature (or legal guardian if patient cannot legally consent to services)

Relationship to patient Self Other _______________

Date (mm/dd/yyyy)

Please note: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information concerning a matter material to the claim may be prosecuted under state law.

026565 (01-2013) Premera Blue Cross Blue Shield of Alaska is an Independent Licensee of the Premera Blue Cross Blue Shield Association

Instructions

1. Complete the Medical Travel Support Claim Form in full.

2. Please note your Reference Number on the form in the space provided. This number will be provided in your approval letter from Premera Blue Cross Blue Shield of Alaska. You can also get a Reference Number for approved travel when you call the customer service number on the back of your Premera member card.

3. Include a statement or letter from your physician certifying the medical need to extend your stay

past the recommended travel duration guidelines (as detailed in your approval letter).

4. Include receipts for all covered travel expenses

5. Include one of the following: a) The boarding pass and a copy of the ticket from the airline or other transportation carrier. The

tickets must state the names of the passenger(s), dates, total cost of travel, and the place of origination and final destination.

b) A copy of the detailed itinerary from the airline, transportation carrier, travel agency or online

travel Web site. The itinerary must identify the name of the passenger(s), the dates of travel and total cost of travel, and the origination and final destination points.

6. Send your completed Medical Travel Support Claim Form with the required documents to:

Premera Blue Cross Blue Shield of Alaska P.O. Box 240609 Anchorage, AK 99524-0609.

We will not be able to process your claim unless you provide all of the information listed above.