Health Insurance Claim Form
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1
2HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
PICA
PICA
1.
1a.
(For Program in Item 1)
MEDICARE
MEDICAID
TRICARE
CHAMPVA
GROUP
FECA
OTHER
INSURED’S ID NUMBER
HEALTH PLAN
BLK LUNG
(Medicare#)
(Medicaid#)
(ID# / DoD#)
(Member ID#)
(ID#)
(ID#)
(ID#)
2.
PATIENT’S NAME
3.
PATIENT’S BIRTH DATE
SEX
4.
INSURED’S NAME
(Last Name, First Name, Middle Initial)
(Last Name, First Name, Middle Initial)
MM
DD
YY
M
F
5.
PATIENT’S ADDRESS
6.
PATIENT RELATIONSHIP TO INSURED
7.
INSURED’S ADDRESS
(No., Street)
(No., Street)
Self
Spouse
Child
Other
STATE
CITY
STATE
8.
RESERVED FOR NUCC USE
CITY
ZIP CODE
TELEPHONE
ZIP CODE
TELEPHONE
(Include Area Code)
(Include Area Code)
(
)
(
)
9.
OTHER INSURED’S NAME
10.
IS PATIENT’S CONDITION RELATED TO:
11.
INSURED’S POLICY GROUP OR FECA NUMBER
(Last Name, First Name, Middle Initial)
a.
a.
a.
OTHER INSURED’S POLICY OR GROUP NUMBER
EMPLOYMENT?
INSURED’S DATE OF BIRTH
SEX
(Current or Previous)
MM
DD
YY
YES
NO
M
F
b.
b.
b.
RESERVED FOR NUCC USE
AUTO ACCIDENT?
PLACE
OTHER CLAIM ID
(State)
(Designated by NUCC)
YES
NO
c.
RESERVED FOR NUCC USE
c.
OTHER ACCIDENT?
c.
INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
d.
10d.
d.
INSURANCE PLAN NAME OR PROGRAM NAME
CLAIM CODES
IS THERE ANOTHER HEALTH BENEFIT PLAN?
(Designated by NUCC)
YES
NO
If yes, complete items 9, 9a, and 9d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13.
INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment of
12.
PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary to process this
medical benefits to the undersignd physician or supplier for services described
claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.
below.
SIGNED
DATE
SIGNED
14.
DATE OF CURRENT ILLNESS, INJURY OR PREGNANCY
15.
16.
DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
(LMP)
OTHER DATE
MM
DD
YY
MM
DD
YY
MM
DD
YY
MM
DD
YY
QUAL.
QUAL.
FROM
TO
17.
18.
NAME OF REFERRING PROVIDER OR OTHER SOURCE
HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17a.
MM
DD
YY
MM
DD
YY
FROM
TO
17b.
NPI
19.
20.
ADDITIONAL CLAIM INFORMATION
OUTSIDE LAB?
$ CHARGES
(Designated by NUCC)
YES
NO
21.
22.
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
ICD Ind.
RESUBMISSION CODE
ORIGINAL REF. NO.
Relate A-L to service line below (24E)
A.
B.
C.
D.
23.
E.
F.
G.
H.
PRIOR AUTHORIZATION NUMBER
I.
J.
K.
L.
24.
A. DATE(S) OF SERVICE
B.
C.
D. PROCEDURES, SERVICES, OR SUPPLIES
E.
F.
G.
H.
I.
J.
(Explain Unusual Circumstances)
PLACE OF
DIAGNOSIS
DAYS OR
EPSDT
ID.
RENDERING
FROM
TO
FAMILY
SERVICE EMG
CPT/HCPCS
MODIFIER
POINTER
$ CHARGES
UNITS
QUAL
PROVIDER ID. #
MM
DD
YY
MM
DD
YY
PLAN
1
NPI
2
NPI
3
NPI
4
NPI
5
NPI
6
NPI
25.
26.
27.
28.
29.
30.
FEDERAL TAX I.D. NUMBER
PATIENT’S ACCOUNT NO.
ACCEPT ASSIGNMENT?
TOTAL CHARGE
AMOUNT PAID
Rsvd for NUCC Use
SSN EIN
(For govt. claims, see back)
$
$
YES
NO
(
)
31.
SIGNATURE OF PHYSICIAN OR SUPPLIER
32.
SERVICE FACILITY LOCATION INFORMATION
33.
BILLING PROVIDER INFO & PHONE #
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse apply
to this bill and are made a part thereof.)
a.
b.
a.
b.
SIGNED
DATE
NUCC Instruction Manual available at:
PLEASE PRINT OR TYPE
APPROVED OMB-0938-1197 FORM 1500 (02-12)
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