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04HQ1094 R12/12 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service Indemnity Company. O. Box 98031 Baton Rouge Louisiana 70898-9031 Phone 800-842-2015 Fax 877-837-5922 PATIENT DATA Last Name First Name Policy Number Date of Birth Age Contact Name Fax Number REQUESTING PHYSICIAN DATA BCBSLA Provider Number Area of Practice/Specialty Name of Place of Treatment Treatment Ctr Provider Phone Number Diagnosis Code s ICD-10 Provider Address CPT-4/HCPCS Code Other Codes...
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