Form Rrb-1500 - Oxford Health Insurance Claim Form
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1
2Oxford Health Plans
PLEASE
P.O. Box 7082
DO NOT
Bridgeport, CT 06601-7082
STAPLE
IN THIS
AREA
APPROVED OMB-0938-0008
HEALTH INSURANCE CLAIM FORM
PICA
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER 1a. INSURED’S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLACK 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 BIRTHDATE
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
MM
DD
YY
SEX
M
F
5. PATIENT’S ADDRESS (No., Street)
6 PATIENT’S RELATIONSHIP TO INSURED
7. INSURED’S ADDRES (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
YES
NO
MM
DD
YY
M
F
b. OTHER INSURED’S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State) b. EMPLOYER’S NAME OR SCHOOL NAME
MM
DD
YY
YES
NO
| ______ |
M
F
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 9a–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 ________________________________________________
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE
MM
DD
YY
MM
DD
YY
MM
DD
YY
PREGNANCY (LMP)
FROM
TO
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
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS EPSDT
From
To
of
of
(Explain Unusual Circumstances)
DIAGNOSIS
OR
Family EMG
COB
RESERVED FOR
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
CODE
$ CHARGES
UNITS
Plan
LOCAL USE
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 BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-92)
FORM OWCP-1500
FORM RRB-1500
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