Cms 1500 - Health Insurance Claim Form - Usrds
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1
2PLEASE
DO NOT
STAPLE
IN THIS
AREA
HEALTH INSURANCE CLAIM FORM
PICA
PICA
GROUP
FECA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
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
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
SEX
MM
DD
YY
■
■
F
M
5. PATIENT’S ADDRESS (No., Street)
6. PATIENT 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
■
■
■
■
M
F
YES
NO
b. OTHER INSURED’S DATE OF BIRTH
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER’S NAME OR SCHOOL NAME
SEX
MM
DD
YY
■
■
■
■
F
YES
NO
M
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.
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
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
14. DATE OF CURRENT:
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
MM
DD
YY
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE
MM
DD
YY
FROM
TO
PREGNANCY(LMP)
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
DAYS
EPSDT
PROCEDURES, SERVICES, OR SUPPLIES
Place
Type
DATE(S) OF SERVICE
RESERVED FOR
DIAGNOSIS
To
From
OR
Family
of
of
(Explain Unusual Circumstances)
COB
$ CHARGES
EMG
LOCAL USE
CODE
UNITS
Plan
MM
DD
YY
MM
DD
YY
Service
Service
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
(For govt. claims, see back)
■
■
■
■
YES
NO
$
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN’S, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
SIGNED
DATE
PIN#
GRP#
APPROVED OMB-0938-0008 FORM CMS-1500 (12-90), FORM RRB-1500,
PLEASE PRINT OR TYPE
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
APPROVED OMB-1215-0055 FORM OWCP-1500,
APPROVED OMB-0720-0001 (CHAMPUS)
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