Health Insurance Claim Form
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MAIL COMPLETED CLAIM FORM TO THE
ADDRESS SHOWN ON YOUR ID CARD.
HEALTH INSURANCE CLAIM FORM
PICA
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED’S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
(Medicare #)
(Medicaid #)
(Sponsor’s SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
3. PATIENT’S BIRTH DATE
SEX
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. PATIENT STATUS
CITY
STATE
Single
Married
Other
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
Employed
Full-Time
Part-Time
(
)
(
)
Student
Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT’S CONDITION RELATED TO:
11. INSURED’S POLICY GROUP OR FECA NUMBER
a. OTHER INSURED’S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED’S DATE OF BIRTH
SEX
MM
DD
YY
YES
NO
M
F
b. OTHER INSURED’S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER’S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
NO
c. EMPLOYER’S NAME OR SCHOOL NAME
c. OTHER ACCIDENT?
c. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
NO
If yes, return to and complete item 9 a-d.
12.
PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE - I authorize the release of any medical or other information
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE - I authorize
necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts
payment of medical benefits to the undersigned physician or supplier for
assignment below.
services described below.
SIGNED
DATE
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS,
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
INJURY (Accident) OR
GIVE FIRST DATE
MM
DD
YY
MM
DD
YY
MM
DD
YY
MM
DD
YY
PREGNANCY (LMP)
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1, 2, 3, OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
.
.
1.
3.
23. PRIOR AUTHORIZATION NUMBER
.
.
2.
4.
24.
A
B
C
D
E
F
G
H
I
J
K
PROCEDURES, SERVICES, OR SUPPLIES
DATE(S) OF SERVICE
Place
Type
DAYS
EPSDT
DIAGNOSIS
RESERVED FOR
$ CHARGES
EMG
COB
(Explain Unusual Circumstances)
From
To
of
of
OR
Family
CODE
LOCAL USE
Service
Service
UNITS
Plan
MM
DD
YY
MM
DD
YY
CPT/HCPCS
MODIFIER
1.
2.
3.
4.
5.
6.
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT’S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
YES
NO
$
$
$
33. PHYSICIAN’S, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
& PHONE #
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
SIGNED
DATE
PIN #
GRP #
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
APPROVED OMB-0938-0008 FORM HCFA-1500 (12-90), FORM RRB-1500,
APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS)
586625 3-02
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