Cms-1500 (Professional)

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APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
PICA
PICA
1.
MEDICARE
MEDICAID
TRICARE
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED’S I.D. NUMBER
(For Program in Item 1)
CHAMPUS
HEALTH PLAN
BLK LUNG
(Medicare #)
(Medicaid #)
(Sponsor’s SSN)
(Member ID#)
(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)
7. INSURED’S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
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)
Full-Time
Part-Time
(
)
(
)
Employed
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)
SEX
a. INSURED’S DATE OF BIRTH
MM
DD
YY
M
F
YES
NO
b. OTHER INSURED’S DATE OF BIRTH
b. AUTO ACCIDENT?
b. EMPLOYER’S NAME OR SCHOOL NAME
SEX
PLACE (State)
MM
DD
YY
NO
M
F
YES
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.
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
ILLNESS (First symptom) OR
14. DATE OF CURRENT:
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
MM
DD
YY
MM
DD
YY
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE
FROM
TO
PREGNANCY(LMP)
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 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.
DATE(S) OF SERVICE
B.
C.
D.
PROCEDURES, SERVICES, OR SUPPLIES
E.
F.
G.
H.
I.
J.
DAYS
EPSDT
From
To
PLACE OF
DIAGNOSIS
RENDERING
(Explain Unusual Circumstances)
ID.
OR
Family
MM
DD
YY
MM
DD
YY
EMG
CPT/HCPCS
MODIFIER
POINTER
$ CHARGES
PROVIDER ID. #
SERVICE
QUAL.
UNITS
Plan
1
NPI
2
NPI
3
NPI
4
NPI
5
NPI
6
NPI
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT’S ACCOUNT NO.
(
For govt. claims, see back
)
$
$
$
YES
NO
(
)
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.)
NPI
NPI
a.
b.
a.
b.
SIGNED
DATE
NUCC Instruction Manual available at:
APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)
RESET

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