Please complete all information requested on the form. Missing information may delay the process of the claim. If you have any questions, contact Patient Claims at (504)592-1533
<br> <br>
The Blood Center will review the form, then process the claim for payment.
<br><br>
Alternatively, you can also print out and submit a paper form: <a href="https://cms.thebloodcenter.org/sites/default/files/2020-08/BloodAssuranceClaimForm.pdf">Click here to download the form.</a>


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<div data-wrapper-react="true">
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="first">
<input type="text" id="first_40" name="q40_name40[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_40 sublabel_40_first" />
<label class="form-sub-label" for="first_40" id="sublabel_40_first" style="min-height:13px" aria-hidden="false"> First Name </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="last">
<input type="text" id="last_40" name="q40_name40[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_40 sublabel_40_last" />
<label class="form-sub-label" for="last_40" id="sublabel_40_last" style="min-height:13px" aria-hidden="false"> Last Name </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_phone" id="id_62">
<label class="form-label form-label-top form-label-auto" id="label_62" for="input_62_full"> Phone Number </label>
<div id="cid_62" class="form-input-wide" data-layout="half">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" id="input_62_full" name="q62_phoneNumber[full]" data-type="mask-number" class="mask-phone-number form-textbox validate[Fill Mask]" style="width:310px" data-masked="true" value="" placeholder="(000) 000-0000" data-component="phone" aria-labelledby="label_62 sublabel_62_masked" />
<label class="form-sub-label" for="input_62_full" id="sublabel_62_masked" style="min-height:13px" aria-hidden="false"> Please enter a valid phone number. </label>
</span>
</div>
</li>
<li class="form-line" data-type="control_datetime" id="id_41">
<label class="form-label form-label-top form-label-auto" id="label_41" for="lite_mode_41"> Date of Birth </label>
<div id="cid_41" class="form-input-wide" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="month_41" name="q41_dateOf41[month]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" autoComplete="off" aria-labelledby="label_41 sublabel_41_month" />
<span class="date-separate" aria-hidden="true">
-
</span>
<label class="form-sub-label" for="month_41" id="sublabel_41_month" style="min-height:13px" aria-hidden="false"> Month </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="day_41" name="q41_dateOf41[day]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" autoComplete="off" aria-labelledby="label_41 sublabel_41_day" />
<span class="date-separate" aria-hidden="true">
-
</span>
<label class="form-sub-label" for="day_41" id="sublabel_41_day" style="min-height:13px" aria-hidden="false"> Day </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="year_41" name="q41_dateOf41[year]" size="4" data-maxlength="4" data-age="" maxLength="4" value="" autoComplete="off" aria-labelledby="label_41 sublabel_41_year" />
<label class="form-sub-label" for="year_41" id="sublabel_41_year" style="min-height:13px" aria-hidden="false"> Year </label>
</span>
</div>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_41" size="12" data-maxlength="12" maxLength="12" data-age="" value="" data-format="mmddyyyy" data-seperator="-" placeholder="MM-DD-YYYY" autoComplete="off" aria-labelledby="label_41 sublabel_41_litemode" />
<img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_41_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="true" data-allow-time="No" data-version="v2" />
<label class="form-sub-label" for="lite_mode_41" id="sublabel_41_litemode" style="min-height:13px" aria-hidden="false"> Date </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_address" id="id_42">
<label class="form-label form-label-top form-label-auto" id="label_42" for="input_42_addr_line1"> Address </label>
<div id="cid_42" class="form-input-wide" data-layout="full">
<div summary="" class="form-address-table jsTest-addressField">
<div class="form-address-line-wrapper jsTest-address-line-wrapperField">
<span class="form-address-line form-address-street-line jsTest-address-lineField">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" id="input_42_addr_line1" name="q42_address42[addr_line1]" class="form-textbox form-address-line" value="" data-component="address_line_1" aria-labelledby="label_42 sublabel_42_addr_line1" required="" />
<label class="form-sub-label" for="input_42_addr_line1" id="sublabel_42_addr_line1" style="min-height:13px" aria-hidden="false"> Street Address </label>
</span>
</span>
</div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField">
<span class="form-address-line form-address-street-line jsTest-address-lineField">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" id="input_42_addr_line2" name="q42_address42[addr_line2]" class="form-textbox form-address-line" value="" data-component="address_line_2" aria-labelledby="label_42 sublabel_42_addr_line2" />
<label class="form-sub-label" for="input_42_addr_line2" id="sublabel_42_addr_line2" style="min-height:13px" aria-hidden="false"> Street Address Line 2 </label>
</span>
</span>
</div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField">
<span class="form-address-line form-address-city-line jsTest-address-lineField ">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" id="input_42_city" name="q42_address42[city]" class="form-textbox form-address-city" value="" data-component="city" aria-labelledby="label_42 sublabel_42_city" required="" />
<label class="form-sub-label" for="input_42_city" id="sublabel_42_city" style="min-height:13px" aria-hidden="false"> City </label>
</span>
</span>
<span class="form-address-line form-address-state-line jsTest-address-lineField ">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" id="input_42_state" name="q42_address42[state]" class="form-textbox form-address-state" value="" data-component="state" aria-labelledby="label_42 sublabel_42_state" required="" />
<label class="form-sub-label" for="input_42_state" id="sublabel_42_state" style="min-height:13px" aria-hidden="false"> State / Province </label>
</span>
</span>
</div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField">
<span class="form-address-line form-address-zip-line jsTest-address-lineField ">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" id="input_42_postal" name="q42_address42[postal]" class="form-textbox form-address-postal" value="" data-component="zip" aria-labelledby="label_42 sublabel_42_postal" required="" />
<label class="form-sub-label" for="input_42_postal" id="sublabel_42_postal" style="min-height:13px" aria-hidden="false"> Postal / Zip Code </label>
</span>
</span>
</div>
</div>
</div>
</li>
<li class="form-line" data-type="control_divider" id="id_44">
<div id="cid_44" class="form-input-wide" data-layout="full">
<div aria-label="Divider" data-component="divider" style="border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px">
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_5">
<div id="cid_5" class="form-input-wide" data-layout="full">
<div id="text_5" class="form-html" data-component="text">
<p><span style="font-weight: bold; color: #2c2e35;">DONOR IN</span><span style="font-weight: bold; color: #2c2e35;">FORMATION </span><span style="font-weight: bold; color: #2c2e35;">(If </span><span style="font-weight: bold; color: #2c2e35;">diff</span><span style="font-weight: bold; color: #2c2e35;">erent</span> <span style="font-weight: bold; color: #2c2e35;">from </span><span style="font-weight: bold; color: #2c2e35;">pat</span><span style="font-weight: bold; color: #2c2e35;">i</span><span style="font-weight: bold; color: #2c2e35;">ent) </span></p>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_45">
<label class="form-label form-label-top form-label-auto" id="label_45" for="first_45"> Name </label>
<div id="cid_45" class="form-input-wide" data-layout="full">
<div data-wrapper-react="true">
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="first">
<input type="text" id="first_45" name="q45_name[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_45 sublabel_45_first" />
<label class="form-sub-label" for="first_45" id="sublabel_45_first" style="min-height:13px" aria-hidden="false"> First Name </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="last">
<input type="text" id="last_45" name="q45_name[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_45 sublabel_45_last" />
<label class="form-sub-label" for="last_45" id="sublabel_45_last" style="min-height:13px" aria-hidden="false"> Last Name </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_datetime" id="id_6">
<label class="form-label form-label-top form-label-auto" id="label_6" for="lite_mode_6"> Date of Birth: </label>
<div id="cid_6" class="form-input-wide" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="month_6" name="q6_dateOf[month]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" autoComplete="off" aria-labelledby="label_6 sublabel_6_month" />
<span class="date-separate" aria-hidden="true">
/
</span>
<label class="form-sub-label" for="month_6" id="sublabel_6_month" style="min-height:13px" aria-hidden="false"> Month </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="day_6" name="q6_dateOf[day]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" autoComplete="off" aria-labelledby="label_6 sublabel_6_day" />
<span class="date-separate" aria-hidden="true">
/
</span>
<label class="form-sub-label" for="day_6" id="sublabel_6_day" style="min-height:13px" aria-hidden="false"> Day </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="year_6" name="q6_dateOf[year]" size="4" data-maxlength="4" data-age="" maxLength="4" value="" autoComplete="off" aria-labelledby="label_6 sublabel_6_year" />
<label class="form-sub-label" for="year_6" id="sublabel_6_year" style="min-height:13px" aria-hidden="false"> Year </label>
</span>
</div>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_6" size="12" data-maxlength="12" maxLength="12" data-age="" value="" data-format="mmddyyyy" data-seperator="/" placeholder="MM/DD/YYYY" autoComplete="off" aria-labelledby="label_6 sublabel_6_litemode" />
<img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_6_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="true" data-allow-time="No" data-version="v2" />
<label class="form-sub-label" for="lite_mode_6" id="sublabel_6_litemode" style="min-height:13px" aria-hidden="false"> Date </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_7">
<div id="cid_7" class="form-input-wide" data-layout="full">
<div id="text_7" class="form-html" data-component="text">
<p><span style="color: #2c2e35;">Don</span><span style="color: #2c2e35;">o</span><span style="color: #2c2e35;">r </span><span style="color: #2c2e35;">G</span><span style="color: #2c2e35;">r</span><span style="color: #2c2e35;">oup </span><span style="color: #2c2e35;">Affliation </span><span style="color: #2c2e35;">(if </span><span style="color: #2c2e35;">any): </span></p>
</div>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_8">
<label class="form-label form-label-top form-label-auto" id="label_8" for="input_8"> Donor Group Affiliation (if any): </label>
<div id="cid_8" class="form-input-wide" data-layout="half">
<input type="text" id="input_8" name="q8_donorGroup" data-type="input-textbox" class="form-textbox" style="width:310px" size="310" value="" data-component="textbox" aria-labelledby="label_8" />
</div>
</li>
<li class="form-line" data-type="control_divider" id="id_46">
<div id="cid_46" class="form-input-wide" data-layout="full">
<div aria-label="Divider" data-component="divider" style="border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px">
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_9">
<div id="cid_9" class="form-input-wide" data-layout="full">
<div id="text_9" class="form-html" data-component="text">
<p><span style="font-weight: bold;color: #2c2e35;">CONTACT </span><span style="font-weight: bold;color: #2c2e35;">PE</span><span style="font-weight: bold;color: #2c2e35;">RSO</span><span style="font-weight: bold;color: #2c2e35;">N </span><span style="font-weight: bold;color: #2c2e35;">(</span><span style="font-weight: bold;color: #2c2e35;">If </span><span style="font-weight: bold;color: #2c2e35;">n</span><span style="font-weight: bold;color: #2c2e35;">ot </span><span style="font-weight: bold;color: #2c2e35;">pa</span><span style="font-weight: bold;color: #2c2e35;">tient)</span></p>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_47">
<label class="form-label form-label-top form-label-auto" id="label_47" for="first_47"> Name </label>
<div id="cid_47" class="form-input-wide" data-layout="full">
<div data-wrapper-react="true">
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="first">
<input type="text" id="first_47" name="q47_name47[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_47 sublabel_47_first" />
<label class="form-sub-label" for="first_47" id="sublabel_47_first" style="min-height:13px" aria-hidden="false"> First Name </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="last">
<input type="text" id="last_47" name="q47_name47[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_47 sublabel_47_last" />
<label class="form-sub-label" for="last_47" id="sublabel_47_last" style="min-height:13px" aria-hidden="false"> Last Name </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_email" id="id_59">
<label class="form-label form-label-top form-label-auto" id="label_59" for="input_59"> Email </label>
<div id="cid_59" class="form-input-wide" data-layout="half">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="email" id="input_59" name="q59_email" class="form-textbox validate[Email]" style="width:310px" size="310" value="" data-component="email" aria-labelledby="label_59 sublabel_input_59" />
<label class="form-sub-label" for="input_59" id="sublabel_input_59" style="min-height:13px" aria-hidden="false"> example@example.com </label>
</span>
</div>
</li>
<li class="form-line" data-type="control_phone" id="id_48">
<label class="form-label form-label-top form-label-auto" id="label_48" for="input_48_full"> Phone Number </label>
<div id="cid_48" class="form-input-wide" data-layout="half">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" id="input_48_full" name="q48_phoneNumber48[full]" data-type="mask-number" class="mask-phone-number form-textbox validate[Fill Mask]" style="width:310px" data-masked="true" value="" placeholder="(000) 000-0000" data-component="phone" aria-labelledby="label_48 sublabel_48_masked" />
<label class="form-sub-label" for="input_48_full" id="sublabel_48_masked" style="min-height:13px" aria-hidden="false"> Please enter a valid phone number. </label>
</span>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_11">
<label class="form-label form-label-top form-label-auto" id="label_11" for="input_11"> Relationship to Patient: </label>
<div id="cid_11" class="form-input-wide" data-layout="half">
<input type="text" id="input_11" name="q11_relationshipTo" data-type="input-textbox" class="form-textbox" style="width:310px" size="310" value="" data-component="textbox" aria-labelledby="label_11" />
</div>
</li>
<li class="form-line" data-type="control_divider" id="id_49">
<div id="cid_49" class="form-input-wide" data-layout="full">
<div aria-label="Divider" data-component="divider" style="border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px">
</div>
</div>
</li>
<li id="cid_12" class="form-input-wide" data-type="control_head">
<div class="form-header-group header-large">
<div class="header-text httal htvam">
<h1 id="header_12" class="form-header" data-component="header">
INSURANCE INFORMATION
</h1>
</div>
</div>
</li>
<li class="form-line" data-type="control_radio" id="id_51">
<label class="form-label form-label-top form-label-auto" id="label_51" for="input_51"> Does the patient have insurance? </label>
<div id="cid_51" class="form-input-wide" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_51" data-component="radio">
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_51" class="form-radio" id="input_51_0" name="q51_doesThe" value="Yes" />
<label id="label_input_51_0" for="input_51_0"> Yes </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_51" class="form-radio" id="input_51_1" name="q51_doesThe" value="No" />
<label id="label_input_51_1" for="input_51_1"> No </label>
</span>
</div>
</div>
</li>
<li class="form-line form-field-hidden" style="display:none;" data-type="control_checkbox" id="id_60">
<label class="form-label form-label-top form-label-auto" id="label_60" for="input_60"> If yes, which provider? </label>
<div id="cid_60" class="form-input-wide" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_60" data-component="checkbox">
<span class="form-checkbox-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="checkbox" aria-describedby="label_60" class="form-checkbox" id="input_60_0" name="q60_ifYes60[]" value="Medicare" />
<label id="label_input_60_0" for="input_60_0"> Medicare </label>
</span>
<span class="form-checkbox-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="checkbox" aria-describedby="label_60" class="form-checkbox" id="input_60_1" name="q60_ifYes60[]" value="Medicade" />
<label id="label_input_60_1" for="input_60_1"> Medicade </label>
</span>
<span class="form-checkbox-item formCheckboxOther" style="clear:left">
<input type="checkbox" class="form-checkbox-other form-checkbox" name="q60_ifYes60[other]" id="other_60" value="other" aria-label="Other" />
<label id="label_other_60" style="text-indent:0" for="other_60"> Other </label>
<span id="other_60_input" class="other-input-container" style="display:none">
<input type="text" class="form-checkbox-other-input form-textbox" name="q60_ifYes60[other]" data-otherhint="Other" size="15" id="input_60" data-placeholder="Please type another option here" placeholder="Please type another option here" />
</span>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_16">
<div id="cid_16" class="form-input-wide" data-layout="full">
<div id="text_16" class="form-html" data-component="text">
<p><em>If insurance is not Medicare or Medicaid, please provide a copy of the insurance company’s Explanation of Benefits</em></p>
</div>
</div>
</li>
<li class="form-line" data-type="control_divider" id="id_58">
<div id="cid_58" class="form-input-wide" data-layout="full">
<div aria-label="Divider" data-component="divider" style="border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px">
</div>
</div>
</li>
<li class="form-line" data-type="control_fileupload" id="id_63">
<label class="form-label form-label-top form-label-auto" id="label_63" for="input_63"> File Upload </label>
<div id="cid_63" class="form-input-wide" data-layout="full">
<div class="jfQuestion-fields" data-wrapper-react="true">
<div class="jfField isFilled">
<div class="jfUpload-wrapper">
<div class="jfUpload-container">
<div class="jfUpload-text-container">
<div class="jfUpload-icon forDesktop">
<span class="iconSvg dhtupload ">
<svg viewBox="0 0 54 47" version="1.1" xmlns="http://www.w3.org/2000/svg">
<g stroke="none" strokeWidth="1" fill="none">
<g transform="translate(-1506.000000, -2713.000000)">
<g transform="translate(1421.000000, 2713.000000)">
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<p style="text-align: center;"><strong>Please read and sign the release below: </strong></p>
<p><em>I hereby authorize the above-named hospital to release information regarding my blood product usage to The Blood Center. </em></p>
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