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1500
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
PICA
PICA
GROUP
FECA
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
1.
MEDICARE
MEDICAID
TRICARE CHAMPUS
CHAMPVA
OTHER
HEALTH PLAN
BLK LUNG
p
p
p
p
p
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(Medicaid #)
(SSN or ID)
(S
SN)
(ID)
3. PATIENT'S BIRTH DATE
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
SEX
MM
DD
YY
p
p
F
M
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
p
p
p
p
Self
Spouse
Child
Other
8. PATIENT STATUS
CITY
STATE
CITY
STATE
p
p
p
Single
Married
Other
TELEPHONE (Include Area Code)
ZIP CODE
ZIP CODE
TELEPHONE (Include Area Code)
p
p
p
(
)
Employed
Full-Time
Part-Time
Student
Student
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. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
p
p
p
p
YES
NO
M
F
b. OTHER INSURED'S DATE OF BIRTH
PLACE (State)
b. AUTO ACCIDENT?
b. EMPLOYER'S NAME OR SCHOOL NAME
SEX
MM
DD
YY
p
p
p
p
YES
NO
M
F
c. INSURANCE PLAN NAME OR PROGRAM NAME
c. OTHER ACCIDENT?
c. EMPLOYER'S NAME OR SCHOOL NAME
p
p
YES
NO
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
p
p
YES
NO
If yes, return to and complete item 9 a-d.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
payment of medical benefits to the undersigned physician or supplier for
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
services described below.
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
below.
DATE
SIGNED
SIGNED
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
MM
DD
YY
MM
DD
YY
MM
DD
YY
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE
FROM
TO
PREGNANCY(LMP)
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17a.
MM
DD
YY
MM
DD
YY
FROM
TO
17 b. NPI
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
p
p
YES
NO
ORIGINAL REF. 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
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
4.
24. A.
B.
C.
D.
F.
G.
H.
I.
J.
E.
DATE(S) OF SERVICE
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
Place
(Explain Unusual Circumstances)
RENDERING
DIAGNOSIS
ID
To
From
OR
Family
of
PROVIDER ID. #
$ CHARGES
QUAL..
MM
DD
YY
MM
DD
YY
EMG
CPT/HCPCS
MODIFIER
POINTER
UNITS
Plan
Service
1
NPI
2
NPI
3
NPI
4
NPI
5
NPI
6
NPI
SSN
EIN
25. FEDERAL TAX I.D. NUMBER
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
p
p
p
p
$
$
$
YES
NO
32. SERVICE FACILITY LOCATION INFORMATION
(
)
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
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.)
b.
b.
a.
a.
SIGNED
DATE
OMB No. 1240-0044
NUCC Instruction Manual available at:
Expires: 05/31/2016