1. Health Insurance Program:
MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP HP FECA BLK LUNG OTHER
1a. Insured's ID Number
2. Patient's Name
3. DOB (mmddyyyy) and Sex
M F
4. Insured's Name
5. Patient's Address
City
State
Zip Code
Telephone (XXX-XXX-XXXX)
6. Patient Relationship to Insured
Self Spouse Child Other
7. Insured's Address
City
State
Zip Code
Telephone (XXX-XXX-XXXX)
8. Patient's Status
Single Married Other
Employed Full-Time Student Part-Time Student
9. Other Insured's Name
a. Other Insured's Policy or Group Number
a. Other Insured's DOB (mmddyyyy>
M F
c. Employer's Name or School Name
d. Insurance Plan Name or Program Name
10. Patient's Condition Related To:
a. Employment? (Current or Previous)
Yes No
b. Auto Accident Place (State)
Yes No
c. Other Accident?
Yes No
d. Reserved for Local Use
11. Insured's Policy Group or FECA Number
a. Insured's DOB (mmddyyyy) and Sex
M F
b. Employer's Name or School Name
c. Insurance Plan Name or Program Name
d. Is there another Health Benefit Plan?
Yes No
12. Patient's or Authorized Person's Signature
13. Insured's or Authorized Person's Signature
14. Date of Current Illness (mmddyyyy)
15. Similar Illness Date (mmddyyyy)
16. Dates Patient Unable to Work
From:
To:
17. Referring Physician or Source
17b.
NPI
18. Hospitalization Dates
From:
To:
19. Reserved for Local Use
20. Outside Lab (Y/N)
Yes No
$Charges
21. Diagnosis or Nature of Illness
1.
2.
3.
4.
22. Medicade Resubmission - Code
Original Ref No
23. Prior Authorization Number
24. A. Dates of Service From (mmddyy)To (mmddyy)
B.
Place of Service
C.
EMG
D. Procedures, Services or Supplies
CPT/HCPCS Modifier
E.
Diagnosis Pointer
F.
Charges
G.
Days or Units
H.
EPSDT Family Plan
I.
ID. Qual
J.
Rendering Provider ID #
25. Federal Tax ID Number (SSN or EIN)
SSN EIN
26. Patient's Account Number
27. Accept Assignment (Y/N)
Yes No
28. Total Charge
29. Amount Paid
30. Balance Due
31. Signature of Physician or Supplier Including Degrees or Credentials
32. Service Facility Location Information
a.
b.
33. Billing Provider Info and Phone (XXX-XXX-XXXX)
a.
b.