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SAMPLEAPPROVED OMB-0938-1197 FORM 1500 (02-12) PLEASE PRINT OR TYPESAMPLEAPPROVED OMB-0938-1197 FORM 1500 (02-12) PLEASE PRINT OR TYPEAPPROVED OMB-0938-1197 FORM 1500 (02-12) 1a. INSURED S NUMBER (For Program in Item 1)4. INSURED S NAME (Last Name, First Name, Middle Initial)7. INSURED S ADDRESS (No., Street)CITYSTATEZIP CODE TELEPHONE (Include Area Code)11. INSURED S POLICY GROUP OR FECA NUMBERa. INSURED S DATE OF BIRTHb. CLAIM ID (Designated by NUCC)d. IS THERE ANOTHER health BENEFIT PLAN?13. INSURED S OR AUTHORIZED PERSON S SIGNATURE I authorizepayment of medical benefits to the undersigned physician or supplier forservices described INSURANCE CLAIM FORMOTHER1.

APPROVED OMB-0938-1197 FORM 1500 (02-12) 1a. INSURED’S I.D. NUMBER (For Program in Item 1) 4. INSURED’S NAME (Last Name, First Name, Middle Initial) ... HEALTH INSURANCE CLAIM FORM 1. MEDICARE MEDICAID TRICARE CHAMPVA OTHER READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT ’S OR AUTHORIZED …

  Health, Approved, Omb approved