P.O. Box 3018 Missoula, MT 59806‐3018 

(406) 721 ‐2222 Fax (406) 523‐3111  

 

1. Patient Information (Use the identification number from your insurance card or policy holder’s Social Security Number.) 

2. Patient’s name  (First, middle and last of person receiving services)  3. Patient’s date of birth (mm/dd/yyyy) 

4. Participant’s current mailing address (Policy holder’s mailing address: street, city, state, and zip code.) 

5. Diagnosis (Briefly describe the illness, injury, or symptoms requiring treatment.) 

5a. Name of provider (List the  name of the provider as indicated on your bill. Multiple bills from the same provider may be included on the same line as long as they are for the same type of service.) 

5b. Description of services (i.e. hospital admission, chest x-ray, appendectomy, acupuncture, etc.) 

5c. Dates of service or purchase (Inclusive dates may be indicated for bills containing multiple dates of service.) 

5d. Charge (Bills must be itemized to show a separate charge for each service.  If the bill was already paid, please indicate the date it was paid.)  

       

       

       

       

       

       

       

       

       

       

       

       

       

Signature‐ I verify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named above.  Authorization is hereby given to any provider of service, which participated in any way in the patient’s care, to release to the participant’s Plan  any medical information which they deem necessary to adjudicate this claim.     Signature of patient_________________________________________________________     Date ______________________________ 

CLAIM FORM

Itemized Bill Information Each provider’s itemized bill must be attached and must contain:  

 • The provider’s Tax ID number 

• The letterhead indicating the name and address of the person or organization 

providing the service 

• The full name of the patient receiving services 

• A description of each service 

• The charge for each service 

Please complete all items on the claim form.  If the information requested does not apply to the patient, indicate N/A (Not Applicable).  If other insurance is primary, please submit the explanation of benefits from the primary insurance company.  Claims in foreign languages or currency must be translated into English and United States currency.  Completed forms and information should be submitted to Allegiance at the mailing address below or you may fax the claim to Allegiance at (406) 523-3111.   Allegiance Benefit Plan Management, Inc. P.O. Box 3018 Missoula, MT 59806   

 

1 Patient Information Use the identification number from your insurance card or policy holders Social Security Number: 2 Patients name First middle and last of person receiving services: 3 Patients date of birth mmddyyyy: 4 Participants current mailing address Policy holders mailing address street city state and zip code: 5 Diagnosis Briefly describe the illness injury or symptoms requiring treatment: 5a Name of provider List the name of the provider as indicated on your bill Multiple bills from the same provider may be included on the same line as long as they are for the same type of serviceRow1: 5b Description of services IE hospital admission chest x ray appendectomy acupuncture etcRow1: 5c Dates of service or purchase Inclusive dates may be indicated for bills containing multiple dates of serviceRow1: 5d Charge Bills must be itemized to show a separate charge for each service If the bill was already paid please indicate the date it was paidRow1: 5a Name of provider List the name of the provider as indicated on your bill Multiple bills from the same provider may be included on the same line as long as they are for the same type of serviceRow2: 5b Description of services IE hospital admission chest x ray appendectomy acupuncture etcRow2: 5c Dates of service or purchase Inclusive dates may be indicated for bills containing multiple dates of serviceRow2: 5d Charge Bills must be itemized to show a separate charge for each service If the bill was already paid please indicate the date it was paidRow2: 5a Name of provider List the name of the provider as indicated on your bill Multiple bills from the same provider may be included on the same line as long as they are for the same type of serviceRow3: 5b Description of services IE hospital admission chest x ray appendectomy acupuncture etcRow3: 5c Dates of service or purchase Inclusive dates may be indicated for bills containing multiple dates of serviceRow3: 5d Charge Bills must be itemized to show a separate charge for each service If the bill was already paid please indicate the date it was paidRow3: 5a Name of provider List the name of the provider as indicated on your bill Multiple bills from the same provider may be included on the same line as long as they are for the same type of serviceRow4: 5b Description of services IE hospital admission chest x ray appendectomy acupuncture etcRow4: 5c Dates of service or purchase Inclusive dates may be indicated for bills containing multiple dates of serviceRow4: 5d Charge Bills must be itemized to show a separate charge for each service If the bill was already paid please indicate the date it was paidRow4: 5a Name of provider List the name of the provider as indicated on your bill Multiple bills from the same provider may be included on the same line as long as they are for the same type of serviceRow5: 5b Description of services IE hospital admission chest x ray appendectomy acupuncture etcRow5: 5c Dates of service or purchase Inclusive dates may be indicated for bills containing multiple dates of serviceRow5: 5d Charge Bills must be itemized to show a separate charge for each service If the bill was already paid please indicate the date it was paidRow5: 5a Name of provider List the name of the provider as indicated on your bill Multiple bills from the same provider may be included on the same line as long as they are for the same type of serviceRow6: 5b Description of services IE hospital admission chest x ray appendectomy acupuncture etcRow6: 5c Dates of service or purchase Inclusive dates may be indicated for bills containing multiple dates of serviceRow6: 5d Charge Bills must be itemized to show a separate charge for each service If the bill was already paid please indicate the date it was paidRow6: 5a Name of provider List the name of the provider as indicated on your bill Multiple bills from the same provider may be included on the same line as long as they are for the same type of serviceRow7: 5b Description of services IE hospital admission chest x ray appendectomy acupuncture etcRow7: 5c Dates of service or purchase Inclusive dates may be indicated for bills containing multiple dates of serviceRow7: 5d Charge Bills must be itemized to show a separate charge for each service If the bill was already paid please indicate the date it was paidRow7: 5a Name of provider List the name of the provider as indicated on your bill Multiple bills from the same provider may be included on the same line as long as they are for the same type of serviceRow8: 5b Description of services IE hospital admission chest x ray appendectomy acupuncture etcRow8: 5c Dates of service or purchase Inclusive dates may be indicated for bills containing multiple dates of serviceRow8: 5d Charge Bills must be itemized to show a separate charge for each service If the bill was already paid please indicate the date it was paidRow8: 5a Name of provider List the name of the provider as indicated on your bill Multiple bills from the same provider may be included on the same line as long as they are for the same type of serviceRow9: 5b Description of services IE hospital admission chest x ray appendectomy acupuncture etcRow9: 5c Dates of service or purchase Inclusive dates may be indicated for bills containing multiple dates of serviceRow9: 5d Charge Bills must be itemized to show a separate charge for each service If the bill was already paid please indicate the date it was paidRow9: 5a Name of provider List the name of the provider as indicated on your bill Multiple bills from the same provider may be included on the same line as long as they are for the same type of serviceRow10: 5b Description of services IE hospital admission chest x ray appendectomy acupuncture etcRow10: 5c Dates of service or purchase Inclusive dates may be indicated for bills containing multiple dates of serviceRow10: 5d Charge Bills must be itemized to show a separate charge for each service If the bill was already paid please indicate the date it was paidRow10: 5a Name of provider List the name of the provider as indicated on your bill Multiple bills from the same provider may be included on the same line as long as they are for the same type of serviceRow11: 5b Description of services IE hospital admission chest x ray appendectomy acupuncture etcRow11: 5c Dates of service or purchase Inclusive dates may be indicated for bills containing multiple dates of serviceRow11: 5d Charge Bills must be itemized to show a separate charge for each service If the bill was already paid please indicate the date it was paidRow11: 5a Name of provider List the name of the provider as indicated on your bill Multiple bills from the same provider may be included on the same line as long as they are for the same type of serviceRow12: 5b Description of services IE hospital admission chest x ray appendectomy acupuncture etcRow12: 5c Dates of service or purchase Inclusive dates may be indicated for bills containing multiple dates of serviceRow12: 5d Charge Bills must be itemized to show a separate charge for each service If the bill was already paid please indicate the date it was paidRow12: 5a Name of provider List the name of the provider as indicated on your bill Multiple bills from the same provider may be included on the same line as long as they are for the same type of serviceRow13: 5b Description of services IE hospital admission chest x ray appendectomy acupuncture etcRow13: 5c Dates of service or purchase Inclusive dates may be indicated for bills containing multiple dates of serviceRow13: 5d Charge Bills must be itemized to show a separate charge for each service If the bill was already paid please indicate the date it was paidRow13: Date: