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Blue Cross
Blue Shield
9
MEDICAL EXPENSE REPORT
STATE OF ILLINOIS GROUP PROGRAM
233 North Michigan Avenue
Chicago, Illinois 60601
See Other Side For Instructions
Member's I.D. (Social Security) No.:
(335- 50- 12 28) 076- 14- 8830
Date of Birth:
2 - 27 - 23
Patient's Name:
Peasy
Joseph
Sex:
Member's Name:_
Warren Joseph
1605 Biscay Drive
Relationship to Member; self Spouse child
Home Address:
Illinois
Zip: 620 35
City : Godfrey
State:_
I.D. CODE:
By reason of law or employment, is the patient covered under any other health benefit plan?
Yes
XNO
Name other Company, Address, Policy Number:
Name of Policy Holder:
certify that the above information is correct and that the
SIGN
bills attached were incurred by the patient listed above.
HERE
3- 12- 76
Date
PLEASE ASK YOUR ATTENDING PHYSICIAN TO COMPLETE THIS PORTION
COMPLETE DIAGNOSIS: Moderate exogenous obesity; Hypertension; Hypercholesterolemia.
DATE FIRST SEEN BY ME FOR THIS CONDITION: NOV . 25 , 1975
DATE OF ONSET: Indefinite
SIGNATURE OF PHYSICIAN:-
_DATE: 3/22/76
zonset
FOR OFFICE USE ONLY
TOTAL
EXPENSE
PAID BY
NON-ELIGIBLE
EXPENSES
BLUE CROSS
BLUE SHIELD
I. Drugs on Prescription
2. Equipment Renta
3. Prosthetic Appliances
4. Physical Therapy
5. Outpatient/Diagnostic
6. Renal Dialysis
TOTALS $
DEDUCTIBLE
LESS CARRY-OVER CREDIT
REMAINING DEDUCTIBLE .
BALANCE of ELIGIBLE, MEDICAL EXPENSES
Percentage of BALANCE Paid by BLUE CROSS AND BLUE SHIELD
Benefit Period Beginning:
Total Medical Expense
Date of Service:
Payments to Patient
This Year
$
Date Processed
Total Medical Expense
Payments to Member
This Year
$
Processed By:
Contract Code
Type Serv.
Age
Pt. Code
Date of Service
Total Expense
Paid
Disp. Code
Type Serv.
Age
Pt. Code
Date of Service
Total Expense
Paid
Disp. Code
2
Type Serv
Ag
Pt. Code
Date of Service
Total Expense
Paid
Disp. Code
3
Type Serv.
Age
Pt. Code
Date of Service
Total Expense
Paid
Disp. Code
4
Type Serv.
Age
Pt. Code
Date of Service
Total Expense
Paid
Disp. Code
5
Type Serv.
Age
Pt. Code
Date of Service
Total Expense
Paid
Disp. Code
5
$1-6 6-73
TOTAL
Its. ucsT.eau/docs/qyn

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