2012 Health Insurance Claim Form
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1HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
PICA
PICA
MEDICAID
TRICARE
CHAMPVA
OTHER
1a. INSURED’S I.D. NUMBER
(For Program in Item 1)
1. MEDICARE
GROUP
FECA
HEALTH PLAN
BLK LUNG
(ID#)
(Medicare #)
(Medicaid #)
(ID#/DoD#)
(ID#)
(ID#)
(Member ID#)
3. PATIENT’S BIRTH DATE
SEX
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
MM
DD
YY
M
F
7. INSURED’S ADDRESS (No., Street)
5. PATIENT’S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
Self
Spouse
Child
Other
8. RESERVED FOR NUCC USE
STATE
CITY
STATE
CITY
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
(
)
(
)
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
11. INSURED’S POLICY GROUP OR FECA NUMBER
10. IS PATIENT’S CONDITION RELATED TO:
a. OTHER INSURED’S POLICY OR GROUP NUMBER
a. INSURED’S DATE OF BIRTH
a. EMPLOYMENT? (Current or Previous)
SEX
DD
MM
YY
F
YES
NO
M
b. RESERVED FOR NUCC USE
b. OTHER CLAIM ID (Designated by NUCC)
b. AUTO ACCIDENT?
PLACE (State)
NO
YES
c. RESERVED FOR NUCC USE
c. INSURANCE PLAN NAME OR PROGRAM NAME
c. OTHER ACCIDENT?
NO
YES
d. INSURANCE PLAN NAME OR PROGRAM NAME
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
10d. RESERVED FOR LOCAL USE
If yes, complete items 9, 9a and 9d.
YES
NO
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
SIGNED
DATE
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
TO
QUAL.
QUAL.
FROM
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
17a.
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
71b. NPI
FROM
TO
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)
$ CHARGES
20. OUTSIDE LAB?
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
Relate A-L to service line below (24E)
22. RESUBMISSION
ICD Ind.
ORIGINAL REF. NO.
CODE
A.
B.
C.
D.
23. PRIOR AUTHORIZATION NUMBER
E.
F.
G.
H.
I.
J.
K.
L.
D.PROCEDURES, SERVICES, OR SUPPLIES
24. A.
C.
E.
F.
G.
H.
I.
J.
DATE(S) OF SERVICE
B.
DAYS
EPSDT
From
To
(Explain Unusual Circumstances)
DIAGNOSIS
ID.
RENDERING
PLACE OF
OR
Family
MM
DD
YY
MM
DD
YY
CPT/HCPCS
MODIFIER
EMG
POINTER
$ CHARGES
QUAL.
PROVIDER ID. #
SERVICE
UNITS
Plan
1
NPI
2
NPI
3
NPI
4
NPI
5
NPI
6
NPI
26. PATIENT’S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
25. FEDERAL TAX I.D. NUMBER
SSN EIN
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
NO
$
$
YES
$
(
)
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. SERVICE FACILITY LOCATION INFORMATION
33. BILLING PROVIDER INFO & PH #
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
a.
b.
a.
b.
SIGNED
DATE
APPROVED OMB-0938-1197 FORM CMS-1500 (02-12)
PLEASE PRINT OR TYPE
NUCC Instruction Manual available at:
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