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