Commercial

Insurance

Block
1
1a

BCBS

x - other for ind/family plan

x - group plan
ID #

BCBS ID #

Medicare

Medicaid

x-Medicare box

x-Medicaid box

Medicare ID #

Medicaid ID #

2
3

Pt's name LAST, FIRST, MI

Pt's MM DD YYYY; x-gender

4
5
6

PH's name LAST, FIRST, MI

Pt's address/telephone #
X-Pt's relationship to PH

LEAVE BLANK

LEAVE BLANK

LEAVE BLANK

LEAVE BLANK

7
8

PH's address/telephone #
Leave Blank

LEAVE BLANK

LEAVE BLANK

Leave Blank (Secondary

insurance)

9a
9b
9c

Leave Blank (Secondary

insurance)
Leave Blank
Leave Blank

9d

Leave Blank (Secondary

insurance)

x-Pt's condition related to

employment, automobile
accident, or another type of
10a-10c accident

10d
11

Leave Blank
PH's group health plan # (No
hyphens/spaces)

BCBS GROUP #

ENTER NONE

11a

PH's MM DD YYYY; x-gender

11b

Leave blank

11c

PH's commercial health

insurance plan

11d

x-YES or NO whether pt has

secondary insurance

LEAVE BLANK

LEAVE BLANK

PH's BCBS health insurance plaLEAVE BLANK

LEAVE BLANK

LEAVE BLANK

LEAVE BLANK

12

Enter Signature on File or SOF;

leave date blank

13

Enter Signature on File or SOF LEAVE BLANK

14

MM DD YYYY to indicate
symptoms of present illness or
LMP with 431 or 484 attached

15

MM DD YYYY of prior episode of

similar illness, if documented LEAVE BLANK

16

MM DD YYYY of pt's inability to

work due to condition, if
documented
LEAVE BLANK

17
17a
17b
18

FIRST, MIDDILE INITIAL, LAST

name of professional who
referred with applicable
qualifier in front of it: DN, DK,
or DQ.
Leave Blank
Provider's NPI if applicable
Pt's admission & discharge
date (MM DD YY)

LEAVE BLANK
LEAVE BLANK

LEAVE BLANK

LEAVE BLANK

LEAVE BLANK

LEAVE BLANK

LEAVE BLANK

19

Leave blank
x-no if procedure(s) in office; xyes for outside laboratory.
Enter CHARGES

20

21
22

Enter ICD-10-CM Codes; in box

place 0. For ICD-9-CM codes
place 9
Leave Blank

23

Enter prior authorization #,

referral #, precertification #,
or CLIA #

24A
24B

MM DD YY procedure FROM
and TO (if procedure lasted
cosecutive days)
Enter POS code

24C

Leave Blank

24D

Enter CPT/HCPCS Level II codes

w/ applicable modifiers

24E

Enter diagnosis pointer letter

from Block 21

24F

Enter fee charged for each

procedure/service

24G

Enter # of days/units for

procedure/services reported in
Block 24D

24H
24I

Leave Blank
Leave Blank

Medicaid pre-authorization #

Enter E for medical emergency;

otherwise leave blank

E-EPSDT program; F-Family

planning; B-Both. OR leave blank

24J

Enter NPI of provider,

supervising provider, or
DMEPOS.

25
26

Enter provider's SSN or EIN

and indicate (X) which one
Pt's account #

27

X-yes or no for whether the

provider agrees to accept the
assignment

28

Total charges for procedures

reported in Block 24

29
30

Pt's payment toward covered

services only, if none leave
blank
Leave Blank

31

Provider's name/credential and

MMDDYYYY claim was
completed

32
32a
32b

NAME & ADDRESS if services

performed outside provider's
office/pt's home
NPI of facility/supplier
Leave Blank

33
33a
33b

Provider's NAME, BILLING

ADDRESS, TELEPHONE #
NPI of billing provider
Leave Blank

LEAVE BLANK

LEAVE BLANK

Tricare

Worker's Comp

x-TRICARE/CHAMPUS

x- FECA if sumbitted to DFEC;

otherwise x-OTHER

Sponsor's SSN

Pt's SSN

Sponsor's name LAST, FIRST, MI

Pt's employer
x-OTHER

Sponsor's address/telephone #

Employer's address/telephone #

10a. x-YES BOX; 10b-c. x-Pt's

condition related to automobile
accident/ or another type of accident
Enter DD Form 2527 if attached.
Otherwise, leave blank
LEAVE BLANK

LEAVE BLANK

LEAVE BLANK

LEAVE BLANK

ENTER claim # assigned by workers'

compensation third-party payer

LEAVE BLANK

ENTER name of workers'

compensation payer
LEAVE BLANK
LEAVE BLANK
LEAVE BLANK

LEAVE BLANK

Block B28; reffered by military

treatment facility, enter (MTF) and
attach DD Form 2161 or SF 513

Enter prior authorization #

ENTER pre-authorization # assigned

by workers' compensation third party
payer

LEAVE BLANK UNLESS

SECONDARY INSURANCE OS
LISTED

LEAVE BLANK
LEAVE BLANK