Health Insurance Claim Form - Elderplan
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1HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
PICA
PICA
MEDICARE
MEDICAID
TRICARE
CHAMPVA
GROUP HEALTH
FECA BLK LUNG
OTHER
(For Program in item 1)
1.
1a. INSURED'S I.D. NUMBER
PLAN
(Medicare #)
(Medicaid #)
(ID#/DoD#)
(Member ID#)
(ID#)
(ID#)
(ID)
3. PATIENT'S BIRTH DATE
SEX
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
MM
DD
YY
M
F
5. PATIENT'S ADDRESS (No., Street)
6.
PATIENT'S RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
Self
Spouse
Child
Other
CITY
STATE
8. RESERVED FOR NUCC USE
CITY
STATE
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (Include Area Code)
(
)
(
)
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT CONDITION RELATIED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
1548
a. INSURED'S DATE OF BIRTH
a. OTHER INSURED'S POLICY NUMBER OR GROUP NUMBER
a. EMPLOYMENT? (Current or Previous)
SEX
MM
DD
YY
YES
NO
M
F
b. IRESERVED FOR NUCC USE
b. AUTO ACCIDENT?
PLACE (State)
b. OTHER CLAIM ID (Designated by NUCC)
YES
NO
c. RESERVED FOR NUCC USE
c. OTHER ACCIDENT?
c. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
d. INSURANCE PLAN NAME OR PROGRAM NAME
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
10d. CLAIM COODES (Designated by NUCC)
Yes
No
If yes, complete items 9, 9a and 9d
READ BACK OF FORM BEFORE COMPLETEING & SIGNING THIS FORM
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize payment of
12 PATIENT'S OR AUTHORIZIED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary to process
medical benefits to the undersigned physician or supplier for services
this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.
described below
DATE
SIGNED
SIGNED
14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP)
15. OTHER DATE
16.
DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
MM
DD
YY
MM
DD
YY
MM
DD
YY
FROM
TO
QUAL.
QUAL.
18.
HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
17a.
MM
DD
YY
MM
DD
YY
FROM
TO
17b.
NPI
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate A-L to service line below (24E)
22. MEDICAID RESUBMISSION
ICD Ind.
CODE
ORIGNAL REF. NO.
C.
A.
B.
D.
23. PRIOR AUTHORIZATION NUMBER
E.
G.
H.
F.
J.
I.
K.
L.
24. A.
DATE(S) OF SERVICE
B.
C,
D.
PROCEDURES, SERVICES OR SUPPLIES
E.
F.
G.
I.
J.
H.
FROM
TO
(Explain Unusual Circumstances)
DIAGNOSIS
RENDERING
PLACE OF
EPSDT
ID.
DAYS OR
Family
MM
DD
YY
MM
DD
YY
EMG
CPT/HCPCS
MODIFIER
POINTER
$ CHARGES
PROVIDER ID. #
SERVICE
UNITS
QUAL
Plan
1
NPI
2
NPI
3
NPI
4
NPI
5
NPI
6
NPI
27 ACCEPT ASSIGNMENT?
25.
FEDERAL TAX I.D. NUMBER
SSN
EIN
26.
PATIENTS ACCOUNT NO.
28. TOTAL CHARGE
29. AMOUNT PAID
30. Rsvd for NUCC Use
(For Govt. Claims, see back)
YES
NO
$
$
SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING
31.
32. SERVICE FACILITY LOCATION INFORMATION
33. BILLING PROVIDER INFO & PH #
DEGREES OR CREDENTIALS (I certify that the
statements on the reverse apply to this bill and are
made part thereof.)
SIGNED
DATE
a.
b.
a.
b.
PLEASE PRINT OR TYPE
NUCC Instruction Manual available at:
APPROVED OMB-0938-1197 FORM 1500 (02-12)
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