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MEDICARE MEDICAID TRICARE CHAMPUS (Sponsors SSN) CHAMPVA GROUP HEALTH PLAN (SSN or ID) FECA BLK LUNG (SSN) SEX M 5. PATIENTS ADDRESS (No., Street) F 7. INSUREDS ADDRESS (No., Street) OTHER 1a. INSUREDS I.D. NUMBER PICA (For Program in Item 1)
(Medicare #)
(Medicaid #)
(Member ID#)
(ID)
4. INSUREDS NAME (Last Name, First Name, Middle Initial)
Employed
(
a. INSUREDS DATE OF BIRTH MM DD YY M b. EMPLOYERS NAME OR SCHOOL NAME
)
SEX F
SEX F
c. INSURANCE PLAN NAME OR PROGRAM NAME NO d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES NO
12. PATIENTS OR AUTHORIZED PERSONS SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. SIGNED 14. DATE OF CURRENT: MM DD YY ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY(LMP) DATE
13. INSUREDS OR AUTHORIZED PERSONS SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below.
SIGNED
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION DD YY MM DD YY MM DD YY GIVE FIRST DATE MM FROM TO
17a. 17b. NPI
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO 20. OUTSIDE LAB? YES NO $ CHARGES
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 1. 3.
22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER
MM
YY
$ CHARGES
DAYS OR UNITS
G.
1 2 3 4 5 6
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27. ACCEPT ASSIGNMENT?
(For
NPI
NPI
NPI
NPI
NPI
NPI
govt. claims, see back)
YES 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) 32. SERVICE FACILITY LOCATION INFORMATION
NO
SIGNED
DATE
a.
NPI
b.
a.
NPI
b.
RESET
2. 24. A.
E. DIAGNOSIS POINTER
F.
H.
I.
CITY
STATE
8. PATIENT STATUS
CITY
STATE
CARRIER