Health Insurance Claim Form Universal
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1
21500
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
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
CHAMPUS
(Medicare #)
(Medicaid #)
(Sponsor’s SSN)
(Member ID#)
(SSN or ID)
(SSN)
(ID)
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
3. PATIENT’S BIRTH DATE
SEX
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
le I
e
MM
DD
YY
M
F
5. PATIENT’S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED’S ADDRESS (No., Street)
Self
Spouse
Child
Other
CITY
STATE
8. PATIENT STATUS
CITY
STATE
STATE
STAT
Single
Married
Other
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (Include Area Code)
TELEPHONE (Include Area Code)
TELEPHONE (Include Area C
Full-Time
Part-Time
(
(
(
)
)
)
(
)
Employed
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
POLICY GROUP OR FECA NUMBER
FECA NUMBER
a. EMPLOYMENT? (Current or Previous)
a. OTHER INSURED’S POLICY OR GROUP NUMBER
a. INSURED’S DATE OF BIRTH
RED’S DATE OF BIRTH
RE
SEX
SEX
SEX
MM
MM
MM
DD
DD
YY
YY
M
M
F
F F
YES
NO
b. OTHER INSURED’S DATE OF BIRTH
b. AUTO ACCIDENT?
SEX
b. EMPLOYER’S NAME OR SCHOOL NAME
b. EMPLOYER’S NAME OR SCHOOL NAME
b. EMPLOYER’S NA
PLACE (State)
MM
DD
YY
YES
NO
M
F
c. EMPLOYER’S NAME OR SCHOOL NAME
c. OTHER ACCIDENT?
c. INSURANCE PLAN NAME OR PROGRAM NAME
c. INSURANCE PLAN NAME OR PROGRAM NAME
RANCE PLAN NAME OR PROGRAM NAME
YES
NO
d. INSURANCE PLAN NAME OR PROGRAM NAME
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
d. IS THERE ANOTHER HEALTH BENEFIT P
d. IS THERE ANOTHER HEALTH BENEFIT
10d. RESERVED FOR LOCAL USE
E
YES
YES
NO
NO
NO
If yes , return to and complete item 9 a-d.
If yes
If yes , re
s s
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize
13. INSURED’S OR AUTHORIZED P
13. INSURED’S OR AUTHORIZED
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary
other information necessary
ther information ne
payment of medical benefits to the undersigned physician or supplier for
payment of medical benefits to
payment of medical benefits t
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
y who accepts assignment
ho accepts assignment
services described below.
services described below.
serv
below.
SIGNED
DATE
ATE
TE
SIGNED
SIGNED
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
NT HAS HAD SAME OR SIMILAR ILLNESS.
T HAS HAD SAME OR SIMILAR ILLNESS.
14. DATE OF CURRENT:
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
16. DATES PATIE
16. D
MM
DD
YY
MM
MM
MM
DD
DD
DD
YY
YY
YY
MM
MM
DD
YY
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE
IRST DATE
RST DATE
FROM
FROM
FRO
TO
PREGNANCY(LMP)
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
18. HOSP
18. HOSP
17a.
MM
DD
YY
MM
DD
YY
17b. NPI
17b.
7
NPI
FROM
F F
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
2
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)
Relate Items 1, 2, 3 or 4 to Item 24E by Line)
ate Items 1, 2, 3 or 4 to Item 24E by Line)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
1.
3.
3. 3.
23. PRIOR AUTHORIZATION NUMBER
2.
4.
4.
24. A.
DATE(S) OF SERVICE
B.
B. B.
C.
C.
C
D.
D.
PROCEDURES, SERVICES, OR SUPPLIES
PROCEDURES, SERVICES, OR SUP
RES, SERVICES,
E.
F.
G.
H.
I.
J.
DAYS
EPSDT
From
To
PLACE OF
PLACE OF
PLACE OF
(Explain Unusual Circumstances)
(Explain Unusual Circumstances)
usual Circumstanc
DIAGNOSIS
RENDERING
ID.
OR
Family
MM
DD
YY
MM
DD
YY
YY
YY
SERVICE
SERVICE
SERVICE
EMG
EMG
EMG
CPT/HCPCS
CPT/HCPCS
CPT/HCPCS
MODIFIER
MODI
MOD
POINTER
$ CHARGES
PROVIDER ID. #
UNITS
Plan
QUAL.
1
NPI
2
NPI
3
NPI
4
NPI
5
5
NPI
6
NPI
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
25. FEDERAL TAX I.D. NUMBER
AL TAX I.D. NUMBER
I.D. NUMBER
SSN EIN
S
S
26. PATIENT’S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
(
For govt. claims, see back
)
YES
NO
$
$
$
(
)
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
PHYSICIAN
YSIC
32. SERVICE FACILITY LOCATION INFORMATION
33. BILLING PROVIDER INFO & PH #
INCLUDING DEGREES OR CREDENTIALS
EES OR
(I certify that the statements on the reverse
me
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-0938-0999 FORM CMS-1500 (08-05)
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