Harvard Pilgrim Health Care Claim Form Page 2
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2ASSIGNMENT OF BENEFITS
PAYMENT WILL BE MADE DIRECTLY TO THE PROVIDER, IF YOU SIGN BELOW.
I AUTHORIZE PAYMENT OF BENEFITS TO THE PHYSICIAN OR PROVIDER DESCRIBED BELOW OR AS INDICATED ON THE ENCLOSED BILL. I UNDER-
STAND THAT I AM FINACIALLY RESPONSIBLE TO THE PROVIDER FOR CHARGES IN EXCESS OF THE PLAN’S PAYMENT SCHEDULE OR CHARGES NOT
COVERED BY MY BENEFIT PLAN.
SIGNED (SUBSCRIBER)
DATE
OR
PAYMENT WILL BE MADE DIRECTLY TO YOU, IF YOU SIGN BELOW.
I AUTHORIZE REIMBURSEMENT OF BENEFITS TO MYSELF FOR SERVICES DESCRIBED BELOW OR AS INDICATED ON THE ENCLOSED BILL. I UNDER-
STAND THAT I AM FINANCIALLY RESPONSIBLE TO THE PROVIDER FOR CHARGES IN EXCESS OF THE PLAN’S PAYMENT SCHEDULE OR CHARGES
NOT COVERED BY MY BENEFIT PLAN.
SIGNED (SUBSCRIBER)
DATE
PLEASE NOTE:
PAYMENT FOR SERVICES RENDERED BY CONTRACTED/IN-NETWORK PROVIDERS WILL BE MADE TO THE PHYSICIAN OR PROVIDER OF SERVICE.
TO THE HOSPITAL –
ATTACH FULLY COMPLETED UB-92 BILLING FORM.
OR
ATTACH FULLY ITEMIZED STATEMENT OF CHARGES AND CREDITS.
PHYSICIAN’S/SURGEON’S STATEMENT
– COMPLETE FOLLOWING OR ATTACH FULLY COMPLETED HCFA 1500 FORM
PATIENT’S NAME:
FIRST
INITIAL
LAST
DATE OF BIRTH
DATE OF
ILLNESS (FIRST SYMPTOM) OR
DATE FIRST CONSULTED YOU
HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS?
INJURY (ACCIDENT) OR
FOR THIS CONDITION
o
o
YES
NO
PREGNANCY (LMP)
DATE PATIENT ABLE TO RETURN
DATES OF TOTAL DISABILITY
DATES OF PARTIAL DISABILITY
TO WORK
FROM
THROUGH
FROM
THROUGH
NAME OF REFERRING PHYSICIAN OR OTHER SOUCE (e.g. public health agency)
FOR SERVICES RELATED TO HOSPITALIZATION
GIVE HOSPITALIZATION DATES
ADMITTED
DISCHARGED
NAME & ADDRESS OF FACILITY WHERE SERVICES RENDERED (if other than home or office)
WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE?
o
o
NO
YES
CHARGES
DIAGNOSIS AND CONCURRENT CONDITIONS
SECONDARY
ICD9-CM CODE
PRIMARY
ICD9-CM CODE
PLACE OF SERVICE (POS)
• 1 – Inpatient Hospital
• 4 – Patient’s Home
• 7 – Nursing Home
• 10 – Other Locations
• 13 – Hospital Emergency Room
• 2 – Outpatient Hospital
• 5 – Day Care Facility
• 8 – Skilled Nursing Facility
• 11 – Independent Laboratory
• 3 – Doctor’s Office
• 6 – Night Care Facility
• 9 – Ambulance
• 12 –
Other Medical/Surgical Facility
SERVICES RENDERED
No.
DO NOT USE
DESCRIBE EACH SERVICE
PROCEDURE
AMOUNT
THESE SPACES
OF
POS.
SEPARATELY
NUMBER
BILLED
FROM
TO
SVCS.
A
AA
O
R
YOUR SOCIAL SECURITY NO.
TOTAL CHARGE
AMOUNT PAID
BALANCE DUE
SIGNATURE OF PHYSICIAN OR SUPPLIER
SIGNED ________________________________ DATE ____________
PHYSICIAN’S OR SUPPLIER’S NAME, ADDRESS, ZIP
YOUR EMPLOYER I.D. NO.
YOUR PATIENT’S ACCOUNT NO.
CODE & TELEPHONE NO.
I.D. NO.
AUTHORIZATIONS TO ASSIGN BENEFITS WILL NOT BE HONORED UNLESS YOUR TAX IDENTIFICATION OR SOCIAL SECURITY NUMBER IS SHOWN.
*PLACE OF SERVICE CODES
4 – (H) – PATIENT’S HOME
7 – (NH) – NURSING HOME
O – (OL) – OTHER LOCATIONS
1 – (IH) – INPATIENT HOSPITAL
5 –
DAY CARE FACILITY (PSY)
8 – (SNF) – SKILLED NURSING FACILITY
A – (IL) – INDEPENDENT LABORATORY
2 – (OH) – OUTPATIENT HOSPITAL
6 –
NIGHT CARE FACILTY (PSY)
9 –
AMBULANCE
B –
OTHER MEDICAL/SURGICAL
3 – (O) – DOCTOR’S OFFICE
FACILITY
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