Commercial Member Claim Page 2
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1
2PHYSICIAN STATEMENT:
STEP 2.
PLEASE HAVE YOUR PHYSICIAN COMPLETE THE FOLLOWING OR ATTACH AN ITEMIZED BILL, MAKING SURE ALL INFORMATION IS ADDRESSED.
PATIENT INFORMATION (To be completed by the patient)
1. PATIENT NAME
LAST
FIRST
MI
2. RELEASE OF MEDICAL INFORMATION
3. ASSIGNMENT OF MEDICAL BENEFITS
I authorize the release of any medical information necessary to
I authorize payment of medical benefits to the undersigned physician or
process this claim.
supplier for services described below. This authorization is invalid
unless the tax ID # of the provider is given under # 24 below.
SIGNATURE OF PATIENT (parent or guardian if patient is a minor)
DATE
SIGNATURE OF INSURED OR AUTHORIZED PERSON
DATE
X
X
PHYSICIAN OR SUPPLIER INFORMATION
4. DATE OF ILLNESS (first symptoms),
5. DATE YOU WERE FIRST CONSULTED FOR THIS
6. HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS?
INJURY (accident), OR PREGNANCY (LMP)
CONDITION
❑
❑
YES
NO
If yes, date(s)
7. DATE PATIENT ABLE TO RETURN TO WORK
8. DATES OF TOTAL DISABILITY
9. DATES OF PARTIAL DISABILITY
From
Through
From
Through
10. NAME OF REFERRING PHYSICIAN
11. HOSPITALIZATION DATES FOR RELATED SERVICES
Admitted
Discharged
12. NAME AND ADDRESS OF FACILITY WHERE SERVICES RENDERED (if other than home or office)
13. LABORATORY WORK OUTSIDE YOUR OFFICE
❑
❑
None
Yes
Charges
14. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
Relate diagnosis to procedure in column D by reference to number 1, 2, 3 or 4 or DX code. Please give CPT-4 procedure code in C and ICD-9 in D below.
1.
2.
3.
4.
B*
D
A
C – PROCEDURES, MEDICAL SERVICES OR SUPPLIES FURNISHED
E
F
PLACE OF
DIAGNOSIS
DATES OF
CHARGES
(INTERNAL USE)
PROCEDURE CODE
DESCRIPTION
(Explain unusual services or circumstances.)
SERVICE
CODE
SERVICE
(Identify)
15. TOTAL CHARGE
16. AMOUNT PAID
*PLACE OF SERVICE CODES
1
H
- Inpatient Hospital
5
- Day Care Facility (Psy)
9
- Ambulance
2
OH - Outpatient Hospital
6
- Night Care Facility (Psy)
O
OL - Other Location
17. BALANCE DUE
3
O
- Doctor Office
7
NH - Nursing Home
A
IL
- Independent Laboratory
4
H
- Patient Home
8
SNF - Skilled Nursing Facility
B
- Other Medical Surgical Facility
20. PHYSICIAN OR SUPPLIER NAME, ADDRESS,
18. SIGNATURE OF PHYSICIAN OR SUPPLIER
19. ACCEPT ASSIGNMENT? (If yes, tax ID #
must be given below)
ZIP CODE AND TELEPHONE #
❑
❑
X
YES
NO
21. DATE
22. PHYSICIAN SOCIAL SECURITY #
23. YOUR PATIENT ACCOUNT #
24. PHYSICIAN TAX ID #
LICENSE #
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