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Hs215 Unit 5 Assignment 1-Ad

Unformatted text preview: HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 II. PICA PICA ll. 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1) CHAMPUS HEALTH PLAN BLK LUNG D(Medicare #) EWedicaid It) D(5ponsor’s SSN) D (Member [MOD (SSN or ID) D (55”) D (ID) 998 1 1765 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) , MM . DD . W , PatIent, Mary, S 03 I 08 : 8O MEI F I PatIent, Mary, S 5. PATIENT'S ADDRESS (No., Street) 91 Home Street 6. PATIENT RELATIONSHIP TO INSURED Sele Spouse D Child D Other D 7. INSURED'S ADDRESS (No., Street) 91 Home Street CITY STATE 8. PATIENT STATUS Nowhere NV Single D MarriedE OtherD ZIP CODE TELEPHONE (Include Area Code) Full-Time Part-Time 12367-1234 ([0]) 201—8989 Emp'W-‘dIZI Student Student CITY STATE Nowhere NY ZIP CODE TELEPHONE (Include Area Code 12367—1234 ( 101) 201-8989 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) D YES E NO b. AUTO ACCIDENT? PLACE (State) U YES E NO c. 0TH ER ACCIDENT? Em D YES 10d. RESERVED FOR LOCAL USE b. OTHER INSURED'S DATE OF BIRTH MM . DD . YY I I SE I I l MD c. EMPLOYER'S NAME OR SCHOOL NAME X PEI d. INSURANCE PLAN NAME OR PROGRAM NAME 11. INSURED'S POLICY GROUP 0R FECA NUMBER a. INSURED'S DATE OF BIRTH SEX MM | DD I YY 03 I 08 I 1980 MD F E b. EMPLOYER’S NAME OR SCHOOL NAME c. INSURANCE PLAN NAME OR PROGRAM NAME II - a ' . ' o (I. IS THERE ANOTHER HEALTH BENEFIT PLAN? D YES Q NO Ifyes, return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT’S OR AUTHORIZED PERSON‘S 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 _SIGNATURE ON FILE ILLNESS (First symptom) OR DATE 14. DATE OF CURRENT: 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. SIGNED SIGNATURE ON FILE 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION (For govt. claims, see back) _2 El YES D No 32. SERVICE FACILITY LOCATION INFORMATION Erin A. Helper, MD. 101 Medic Drive 114234523 El E 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.) Am ber Whitecavag e 9/7/16 SIGNED DATE NUCC Instruction Manual available at: www.nucc.org 3- 1234567890 3_ 1234567890 _ MMI DD I W INJURY(ACCident)OR GIVE FIRSTDATE MM I DD I W MMI DD . W MMI DD . YY 01 ' 05 ' YYY PREGNANCY(LMP) I I FROM I I To I I 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17; 18. HOSPITALIZATION DATES RELATED To CURRENT SERVICES 7 MM| DDIYY MMIDD|YY 17b. FROM : : TO : : 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? a CHARGES DYES leNo I 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. No. 1. DLZC.._O_ 3. _ 23. PRIOR AUTHORIZATION NUMBER 2. I_4_0_1._9_ 4. .— 24. A. DATE(S) OF SERVICE B. c. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. J. From To PLACE 0" (Explain Unusual Circumstances) DIAGNOSIS DAYS OR RENDERING MM DD W MM DD W SERV'CE EMG CPT/HCPCS MODIFIER POINTER $CHARGES UNITS PROVIDER ID.# 1 I I I I | I I I a """"" 01 ' 05 "YY) ' ' 11 99386 ' ' ' 1 150 '00 2 . . . . . . . . fl .......... 01 ' 05 I’YY) ' ' 11 99213 25 ' ' ' 2 75 '00 3 I I I I I I I I """"" 01 ' 05 I’YY) ' ' 11 81001 I ' ' 1 10 '00 4 . . . . . . . . fl .......... 01' 05 'YYY ' ' 11 36415 ' ' ' 1 8 '00 5 I I I I I I I : a """"" 6 . . . . . . . . _ _ __________ I I | I I l | | I I I . | | NH I 25. FEDERAL TAX ID. NUMBER SSN EIN 26. PATIENT'S ACCOUNT No. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE * 243 i or: ‘ I ‘ I 33. BILLING PROVIDER INFO & PH # (10 ) 111_1234 Erin A. Helper, MD. PHYSICIAN OR SUPPLIER INFORMATION —>l4— PATIENT AND INSURED INFORMATION —>I4— CARRIER —> 101 Medic Drive APPROVED OMB-0938—0999 FORM CMS—1500 (08-05) ...
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1a. INSURED’S I.D. NUMBER4. INSURED’S NAME (Last Name, First Name, Middle Initial)7. INSURED’S ADDRESS (No., Street)CITY11. INSURED’S POLICY GROUP OR FECA NUMBERa. INSURED’S DATE OF BIRTHd. IS THERE ANOTHER HEALTH BENEFIT PLAN?13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorizepayment of medical benefits to the undersigned physician orsupplier for services described below.FHEALTH INSURANCE CLAIM FORMOTHER1.READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessaryto process this claim. I also request payment of government benefits either to myself or to the party who accepts assignmentbelow.SIGNEDDATEILLNESS (First symptom) ORINJURY (Accident) ORPREGNANCY(LMP)15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.GIVE FIRST DATE14. DATE OF CURRENT:19. RESERVED FOR LOCAL USE21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)FromMMDD