Health Insurance Claim Form
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1
2APPROVED OMB-0938-0008
PO BOX 5077
For services rendered out of area, provider should submit
MIDDLETOWN, NY 10940-9077
claim to the local Blue Cross and Blue Shield plan.
1-866-517-1092
HEALTH INSURANCE CLAIM FORM
Important filing instructions on next page
PICA
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED’S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
WKM
(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 BIRTH DATE
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
MM
DD
YY
SEX
M
F
5. PATIENT’S ADDRESS (No. and Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED’S ADDRESS (No. and Street)
Self
Spouse/DP
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
Network Incentive PPO
a. OTHER INSURED’S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (Current or Previous)
a. INSURED’S DATE OF BIRTH
MM
DD
YY
SEX
YES
NO
M
F
b. OTHER INSURED’S DATE OF BIRTH
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER’S NAME OR SCHOOL NAME
MM
DD
YY
SEX
Cushman & Wakefield
M
F
YES
NO
c. EMPLOYER’S NAME OR SCHOOL NAME
c. OTHER ACCIDENT?
c. INSURANCE PLAN NAME OR PROGRAM NAME
Cushman & Wakefield
YES
NO
d. INSURANCE PLAN NAME OR PROGRAM NAME
d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER NAME OR BENEFIT PLAN?
YES
NO
If YES, return to and complete item 9a– d.
READ BACK OF FORM BEFORE COMPLETING THIS SECTION.
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment
12. I AUTHORIZE THE RELEASE OF INFORMATION AS DESCRIBED ON THE REVERSE SIDE OF THIS CLAIM FORM.
of medical benefits to the undersigned physician or supplier for services
described below.
NOT APPLICABLE
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
MM
DD
YY
MM
DD
YY
MM
DD
YY
PREGNANCY (LMP)
GIVE FIRST DATE
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
ORIGINAL REF. NO.
CODE
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
$ CHARGES
OR
FAMILY
EMG
COB
RESERVED FOR
MM
DD
YY
MM
DD
YY
SERVICE SERVICE
CPT/HCPCS
MODIFIER
CODE
UNITS
PLAN
LOCAL USE
1
2
3
4
5
6
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
YES
NO
$
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER,
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIANS, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (if other than home or office) AND PHONE NUMBER
I CERTIFY THAT THE CARE, SERVICES AND SUPPLIES ENTERED ON THIS
FORM HAVE BEEN RENDERED TO THE PATIENT, AND THAT I AM ENTITLED
TO REIMBURSEMENT OF THE CHARGES INDICATED.
SIGNED
DATE
PIN#
GRP#
PLEASE PRINT OR TYPE
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
FORM HCFA-1500 (12-90)
FORM OWCP-1500
MNYFR2313Y 2/08
Services provided by Empire HealthChoice Assurance, Inc., a licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
FORM #322
PAGE 1 of 2
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