Universal Insurance Claim Form
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1Universal Insurance Claim Form
Please send reimbursement to the patient listed below.
This form replaces HCFA. The patient has paid provider for services.
Patient instruction: Submit a copy of your insurance card and a copy of your bill slip
along with this universal insurance form to your insurance company.
Primary insurance company
Primary insurance company’s address
Street
City
State
Zip Code
Policy holder’s last name
First name
Middle initial
Policy holder’s birthday (month/day/year)
Policy holder’s employer
Date of service
ID number
Group number
Patient’s last name
First name
Middle initial
Patient’s address
Street
City
State
Zip Code
Patient’s home phone
Patient’s date of birth
Referring physician
Federal Tax ID#
68-0643306
Total fees paid out of pocket $
Cash
Check
___________ Credit card
(Include check number)
Patient (or guardian’s) Signature
Insurance company Please see attached encounter form for diagnosis, ICD-9 codes, and procedure codes.
Secondary insurance company
Secondary insurance company’s address
Street
City
State
Zip Code
Secondary insurance policy holder’s last name
First name
Middle initial
Secondary insurance policy holder’s address (if different from above)
Street
City
State
Zip Code
Secondary policy holder’s birthday (month/day/year)
ID number
Group number
Provider signature is provided on the bill slip attached to the universal claim form.
Frisco, TX 75034
7460 Warren Pkwy, Suite 100
Phone: (469) 294-1660
Fax: (855) 758-9784
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Parent category: Legal