Health Insurance Claim Form Universal (Page 2 of 2) in pdf

BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BY

APPLICABLE PROGRAMS.

NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may

be guilty of a criminal act punishable under law and may be subject to civil penalties.

REFERS TO GOVERNMENT PROGRAMS ONLY

MEDICARE AND CHAMPUS PAYMENTS: A patient’s signature requests that payment be made and authorizes release of any information necessary to process

the claim and certifies that the information provided in Blocks 1 through 12 is true, accurate and complete. In the case of a Medicare claim, the patient’s signature

authorizes any entity to release to Medicare medical and nonmedical information, including employment status, and whether the person has employer group health

insurance, liability, no-fault, worker’s compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made. See 42

CFR 411.24(a). If item 9 is completed, the patient’s signature authorizes release of the information to the health plan or agency shown. In Medicare assigned or

CHAMPUS participation cases, the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary as the full charge,

edi

and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge

e based

based

determination of the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submitted. CHAMPUS is not a health insurance program but

health insuran

ealth insura

makes payment for health benefits provided through certain affiliations with the Uniformed Services. Information on the patient’s sponsor should be provided in those

nsor should be pro

sor should be

items captioned in “Insured”; i.e., items 1a, 4, 6, 7, 9, and 11.

BLACK LUNG AND FECA CLAIMS

The provider agrees to accept the amount paid by the Government as payment in full. See Black Lung and FECA instructions regarding required procedure and

ctions regard

tions

regarding required procedure

ing required proce

diagnosis coding systems.

SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE, CHAMPUS, FECA AND BLACK LUNG)

BLACK LUNG)

ACK LUNG)

I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me or were furnished

were personally furnished by me or were furnished

onally furnished by me or were furnished

incident to my professional service by my employee under my immediate personal supervision, except as otherwise expressly permitted by Medicare or CHAMPUS

wise expressly permi

permitted by Medicare or CHAMPUS

tted by Medicare or CHAMPUS

regulations.

For services to be considered as “incident” to a physician’s professional service, 1) they must be rendered under the physician’s immediate personal supervision

ed under the physician’s immediate personal super

mmediate personal supe

by his/her employee, 2) they must be an integral, although incidental part of a covered physician’s service, 3) they must be of kinds commonly furnished in physician’s

e, 3) they must be of

3) t

kinds commonly furnished in ph

only furnished in ph

offices, and 4) the services of nonphysicians must be included on the physician’s bills.

For CHAMPUS claims, I further certify that I (or any employee) who rendered services am not an active duty member of the Uniformed Services or a civilian employee

tive duty member of the Unifor

ve duty membe

med Services or a civ

Services or a civ

of the United States Government or a contract employee of the United States Government, either civilian or military (refer to 5 USC 5536). For Black-Lung claims,

her civilian or military (refer to 5

ivilian or military

USC 5536). For Bl

C 5536). For B

I further certify that the services performed were for a Black Lung-related disorder.

No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations (42 CFR 424.32).

isting law and regulations (42 CFR 424.32

sting law and regulations (42 CFR

424.32).

NOTICE: Any one who misrepresents or falsifies essential information to receive payment from Federal funds requested by this form may upon conviction be subject

ment from Federal funds requested by this fo

ent from Federal funds requested by this

form may

rm may

to fine and imprisonment under applicable Federal laws.

NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE, CHAMPUS, FECA, AND BLACK LUNG INFORMATION

MEDICARE, CHAMPUS, FECA, AND BLACK LU

MEDICARE, CHAMPUS, FECA, AND BLACK L

(PRIVACY ACT STATEMENT)

ACT STATEMENT)

We are authorized by CMS, CHAMPUS and OWCP to ask you for information needed in the administration of the Medicare, CHAMPUS, FECA, and Black Lung

ation needed in the administration of the Medicare

ation needed in the administration of the Medicar

programs. Authority to collect information is in section 205(a), 1862, 1872 and 1874 of the Social Security Act as amended, 42 CFR 411.24(a) and 424.5(a) (6), and

2 and 1874 of the Social Security Act as amended,

nd 1874 of the Social Security

44 USC 3101;41 CFR 101 et seq and 10 USC 1079 and 1086; 5 USC 8101 et seq; and 30 USC 901 et seq; 38 USC 613; E.O. 9397.

C 8101 et seq; and 30 USC 901 et seq; 38 USC 6

C 8101 et seq; and 30 USC 901

The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility. It is also used to decide if the services

ms is used to identify you and to determine your el

ms is used to identify you and to

and supplies you received are covered by these programs and to insure that proper payment is made.

d to insure that proper payment is made.

to insure that proper payment is mad

The information may also be given to other providers of services, carriers, intermediaries, medical review boards, health plans, and other organizations or Federal

vices, carriers, intermediaries, medical review boar

ces, carriers, intermediaries, medical review

agencies, for the effective administration of Federal provisions that require other third parties payers to pay primary to Federal program, and as otherwise necessary

sions that require other third parties payers to pay pr

s that require other third parties payers to pay

to administer these programs. For example, it may be necessary to disclose information about the benefits you have used to a hospital or doctor. Additional disclosures

ecessary to disclose information about the benefits yo

to disclose information about the benefits y

are made through routine uses for information contained in systems of records.

ained in systems of records.

ined in systems of records.

FOR MEDICARE CLAIMS: See the notice modifying system No. 09-70-0501, titled, ‘Carrier Medicare Claims Record,’ published in the Federal Register, Vol. 55

fying system No. 09-70-0501, titled, ‘Carrier Medic

ying system No. 09-70-0501, titled, ‘Carrie

No. 177, page 37549, Wed. Sept. 12, 1990, or as updated and republished.

r as updated and republished.

FOR OWCP CLAIMS: Department of Labor, Privacy Act of 1974, “Republication of Notice of Systems of Records,” Federal Register Vol. 55 No. 40, Wed Feb. 28,

or, Privacy Act of 1974, “Republication of Notice of

r, Privacy Act of 1974, “Republication of Notice o

1990, See ESA-5, ESA-6, ESA-12, ESA-13, ESA-30, or as updated and republished.

A-13, ESA-30, or as updated and republished.

ESA-30, or as updated and republished.

FOR CHAMPUS CLAIMS: PRINCIPLE PURPOSE(S): To evaluate eligibility for medical care provided by civilian sources and to issue payment upon establishment

LE PURPOSE(S):

SE(S):

( )

To evaluate eligibility for medica

To evaluate eligibility for me

of eligibility and determination that the services/supplies received are authorized by law.

t the services/supplies received are authorized by

pplies received are authorized b

ROUTINE USE(S): Information from claims and related documents may be given to the Dept. of Veterans Affairs, the Dept. of Health and Human Services and/or

n from claims and related documents may be given

from claims and related documents may be give

the Dept. of Transportation consistent with their statutory administrative responsibilities under CHAMPUS/CHAMPVA; to the Dept. of Justice for representation of

consistent with their statutory administrative respon

onsistent with their statutory administrative

the Secretary of Defense in civil actions; to the Internal Revenue Service, private collection agencies, and consumer reporting agencies in connection with recoupment

n civil actions; to the Internal Revenue Service, priva

civil actions; to the Internal Revenue Service, pr

claims; and to Congressional Offices in response to inquiries made at the request of the person to whom a record pertains. Appropriate disclosures may be made

sional Offices in response to inquiries made at the

onal Offices in response to inquiries made at the

to other federal, state, local, foreign government agencies, private business entities, and individual providers of care, on matters relating to entitlement, claims

e, local, foreign government agencies, private bus

cal, foreign government agencies, private bu

adjudication, fraud, program abuse, utilization review, quality assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil and

, program abuse, utilization review, quality assura

m abuse, utilization review, quality assura

criminal litigation related to the operation of CHAMPUS.

n related to the operation of CHAMPUS.

the operation of CHAMPUS.

DISCLOSURES: Voluntary; however, failure to provide information will result in delay in payment or may result in denial of claim. With the one exception discussed

RES: Voluntary; however, failure to provide informa

owever, failure to provide informa

below, there are no penalties under these programs for refusing to supply information. However, failure to furnish information regarding the medical services rendered

re are no penalties under these programs for refusin

nder these programs for refusi

or the amount charged would prevent payment of claims under these programs. Failure to furnish any other information, such as name or claim number, would delay

mount charged would prevent payment of claims un

mount charged would prevent payment of c

payment of the claim. Failure to provide medical information under FECA could be deemed an obstruction.

ent of the claim. Failure to provide medical inform

ent of the claim. Failure to provide medica

It is mandatory that you tell us if you know that another party is responsible for paying for your treatment. Section 1128B of the Social Security Act and 31 USC 3801-

is mandatory that you tell us if you know that anothe

s mandatory that you tell us if you know that a

3812 provide penalties for withholding this information.

3812 provide penalties for withholding this inform

3812 provide penalties for withholding this info

You should be aware that P.L. 100-503, the “Computer Matching and Privacy Protection Act of 1988”, permits the government to verify information by way of computer matches.

You should be aware that P.L. 100-503, the “Comp

You should be aware that P.L. 100-503, the “Com

MEDICAID PAYMENTS (PROVIDER CERTIFICATION)

I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the State’s Title XIX plan and to furnish

I hereby agree to keep such records as a

I hereby agree to keep such record

information regarding any payments claimed for providing such services as the State Agency or Dept. of Health and Human Services may request.

information regarding any payments c

information regarding any paymen

I further agree to accept, as payment in full, the amount paid by the Medicaid program for those claims submitted for payment under that program, with the exception

urther agree to accept, as payme

her agree to accept, as paym

of authorized deductible, coinsurance, co-payment or similar cost-sharing charge.

uthorized deductible, coinsu

d deductible, coinsu

SIGNATURE OF PHYSICIAN (OR SUPPLIER): I certify that the services listed above were medically indicated and necessary to the health of this patient and were

TURE OF PHYSICIA

URE OF PHYSICIA

personally furnished by me or my employee under my personal direction.

y furnished by m

NOTICE:

This is to certify that the foregoing information is true, accurate and complete. I understand that payment and satisfaction of this claim will be from Federal and State

is to cert

funds, and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State laws.

and

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB

control number for this information collection is 0938-0999. The time required to complete this information collection is estimated to average 10 minutes per response, including the

time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the

accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland

21244-1850. This address is for comments and/or suggestions only. DO NOT MAIL COMPLETED CLAIM FORMS TO THIS ADDRESS.