Medical Health Care

January **, ****

Dear Provider,

Please accept this letter as a temporary Blue Cross and Blue Shield identification card.

According to the information on file, the following individual(s) have Blue Cross and Blue

Shield coverage:

Subscriber: MELODY G HILBURN

Identification Number: 089*******

Medical Group Number: 000002

Eff date: 02/02/2012

This letter does not guarantee coverage or payment and does not represent prior approval for benefits. All

claims are subject to coverage provisions and medical necessity.

To verify eligibility and product information, please call 1-800-***-****.

ATTENTION PROVIDER: This Temporary ID will automatically expire within 10 days after the date of its

issuance. If you are providing services to this enrollee or his/her dependent after the expiration date, please call the

number listed above to check that the information contained in this letter is still accurate.

Please file all claims with your LOCAL Blue Cross and Blue Shield plan.

Thank you.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the

Blue Cross and Blue Shield Association.

www.bcbstx.com

Contact this candidate