Medical Mutual Of Ohio Claim Form
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1
2DO NOT WRITE IN THE SPACE BELOW
FOR MEDICAL MUTUAL USE ONLY
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S ID NUMBER
NOT REQUIRED BY MEDICAL MUTUAL
HEALTH PLAN
NG
□
□
□
□
□
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(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #1)
(SSN or ID)
(SSN)
(ID)
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
SEX
MM
DD
YY
□
□
M
F
7. INSURED'S ADDRESS (Street No.)
5. PATIENT'S ADDRESS (Street No. )
6. PATIENT RELATIONSHIP TO INSURED
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□
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Self
Spouse
Child
Other
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check here if new address.
CITY
STATE
CITY
STATE
8. PATIENT STATUS
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□
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Single
Married
Other
□
□
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ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
Employed
Full-Time
Part-Time
Student
Student
(
)
(
)
11. INSURED'S POLICY GROUP OR NUMBER
9. OTHER INSURED'S NAME
10. IS PATIENT'S CONDITION RELATED TO:
NOT REQUIRED BY
RECIPROCITY
(Last Name, First Name, Middle Initial)
N
MEDICAL MUTUAL
a. INSURED'S DATE OF BIRTH
SEX
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT?
(CURRENT OR PREVIOUS)
MM
DD
YY
□
□
□
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YES
NO
M
F
b. EMPLOYER'S NAME OR SCHOOL NAME
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
MM
DD
YY
□
□
□
□
M
F
YES
NO (__________)
c. INSURANCE PLAN NAME OR PROGRAM NAME
c. EMPLOYER'S NAME OR SCHOOL NAME
c. OTHER ACCIDENT?
□
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YES
NO
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
□
□
YES
NO If yes, return to and complete item 9 a-d.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize payment of
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE. I authorize the release of any medical or other information
medical benefits to the undersigned physician or supplier for services described
necessary to process this claim.
below.
NOT REQUIRED BY
MEDICAL MUTUAL
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
GIVE FIRST DATE
MM
DD
YY
MM
DD
YY
MM
DD
YY
PREGNANCY (LMP)
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. ID 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
CODE
ORIGINAL REF. NO.
N O T R E Q U I R E D B Y
1. ________ . ___
3. ________ . ___
M E D I C A L M U T U A L
23. PRIOR AUTHORIZATION NUMBER
2. ________ . ___
4. ________ . ___
24.
A
B
C
D
E
F
G
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES OR SUPPLIES
DAYS
(Explain Unusual Circumstances)
From
To
of
of
DIAGNOSIS
OR
RESERVED FOR
MM
DD
YY
MM DD YY
Service
Service
CPT/HCPCS
MODIFIER
CODE
$ CHARGES
UNITS
COB
LOCAL USE
1
2
3
4
5
6
25. FEDERAL TAX ID NUMBER
SSN
EIN
26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
NOT REQUIRED BY
□
□
□
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YES
NO
MEDICAL MUTUAL
$
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S/ SUPPLIER'S BILLING NAME, ADDRESS,
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
ZIP CODE & PHONE #
(I certify that the services were rendered by
me or under my direct supervision.)
____________________________________________
SIGNED
DATE
PIN #
GRP#
SC37 R3/03
Medical Mutual of Ohio
®
Medical Mutual Services, LLC
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