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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. I also request payment of government benefits either to myself or to the party who accepts DATEILLNESS (First symptom) ORINJURY (Accident) ORPREGNANCY(LMP)MM DD YY15.

HEALTH INSURANCE CLAIM FORM 1. MEDICARE MEDICAID TRICARE CHAMPVA OTHER READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. ... APPROVED OMB-0938-0999 FORM CMS-1500 (08-05) 1500 le Ie E LE ... We are authorized by CMS, CHAMPUS and OWCP to ask you for information needed in the administration of the Medicare, …

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Transcription of CMSLC WITH DIMENSIONS - NUCC

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