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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. MEDICARE MEDICAID TRICARE CHAMPVAREAD BACK OF FORM BEFORE COMPLETING & SIGNING THIS PATIENT S OR AUTHORIZED PERSON S SIGNATURE I authorize the release of any medical or other information necessaryto process this claim.

EPSDT Family Plan ID. QUAL. NPI NPI ( ) PLEASE PRINT OR TYPE QUAL. QUAL. R svd for N UC e A. E. I. B. F. J. C. G. K. D. L. H. ICD Ind. IL L N E S S , IN JU R Y o r P R E G N A N C Y (L M P ) (N U C C ) co m p le te ite m s 9 , 9 a a n d 9 d 0 2 /1 2 O T H E R

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