From (Provider Name): ________________________________________________________________________

Fax Number: _______________________________ Phone Number: ________________________________

Office Contact (Sender) Name: _________________________________________________________________

3316 (R10-14)

Date: ________________________________ Number of pages (including cover sheet): _____________

Patient Name: ______________________________________________________________________________

Subscriber Id Number: _________________________________________

Service Date: ________________________________ Total Charges: ________________________________

Provider Legacy and/or NPI Number: ___________________________________________________________

Attachment Control Number: ___________________________________

Please check one of the following:

q This is a first time submitting electronic claim with the PWK indicator reported on the claim.

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Highmark Blue Shield claim number: _____________________________________

PWK (Paperwork) SUPPLEMENTAL CLAIM INFORMATION COVER SHEET

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Attention: Document Preparation/Image

Fax Number: (888) 910-8797

Mailing Address: Highmark Blue Shield PWK (Paperwork) Additional DocumentationPO Box 890176Camp Hill, PA 17089-0176

Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association