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CMSLC WITH DIMENSIONS - NUCC

PLEASE PRINT OR TYPE1a. 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. EMPLOYER S NAME OR SCHOOL NAMEd. 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 FHEALTH INSURANCE CLAIM FORMOTHER1. MEDICARE MEDICAID TRICARE CHAMPVAREAD BACK OF FORM BEFORE COMPLETING & SIGNING THIS PATIENT S OR AUTHORIZED PERSON S SIGNATUREI authorize the release of any medical or other information necessaryto process this claim.

S AM YYYY 5 AL TAX I.D. NUMBER SI.D. NUMBER S PHYSICIAN YSIC EES OR me MPLE FORM M FF YES NONO 33.. 4. ... Authority to collect information is in section 205(a), 1862, 1872 and 1874 of the Social Security Act as amended, 42 CFR 411.24(a) and 424.5(a) (6), and ... ROUTINE USE(S): Information from claims and related documents may be given to the ...

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Transcription of CMSLC WITH DIMENSIONS - NUCC

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