I certify that, to the best of my knowledge, the information on this Medical Claim Form is true and correct. Please complete every item on claim form.This completed form, together with the itemized bills, should be submitted to: Blue Cross and Blue Shield of Illinois. This form is used to reimburse the person who has assumed full responsibility for the funeral and burial expense of a deceased. NOTICE TO ALL PARTIES COMPLETING THIS FORM: It is fraudulent to fill out this form with information you know to be false or to omit important facts. If you are filing a claim, please fill out the reverse side of this form. How do I file a claim? A completed Aetna Claim Form. The online form requires Adobe Acrobat Reader, or you may pick up a form at the Student Health Insurance Office. Forms should be downloaded to your computer before filling in the fields.