Cms 1450 Form - California Victim Compensation Board

ADVERTISEMENT

3
Be advise that before a bill can be considered
1
5
6
“acceptable” for payment by the Victim
12
13
Compensation and Government Claims Board,
the following sections must be completed
correctly or the bill will be returned and
payment may be delayed
38
Section Number on
Information listed below is
needed in each section to
CMS 1450 Form
process your bill
1
Provider Name/Address
3
Claimant’s/Patient’s Account Number
43
46
47
5
Tax ID/SSN/FEIN Number of Payee as
Registered with IRS
6
Dates of Services
12
Claimant’s/Patient’s Name
13
Claimant’s/Patient’s Address
38
Claimant’s/Patient’s Name and Address
43-46
Itemized Expenses
47
Total Charges/Billed Amount
58
Claimant’s/Patient’s Name
60*
Claimant’s VCP Claim Number/SSN
58
60*
67
Primary Diagnosis Code
82 & 85
Physician’s Name/License
Number/Signature/Date
67
82
*Claim Number
is not required if not listed.
ATTENTION ALL PROVIDERS ALREADY IN OUR SYSTEM:
Number 1
and
Number 5
on your bi ll mus t match exactly to what is in th e system. I f
85
YOU/PROVIDER has a new Tax Id please noti fy the Program immediatel y

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go