Health Insurance Program HEALTH INSURANCE CLAIM …

1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHERCHAMPUSHEALTH PLAN BLK LUNG(Medicare #) (Medicaid #) (Sponsor s SSN) (Memberchip ID#) (SSN or ID) (SSN) (ID)2. PATIENT S NAME (Last Name, First Name, Middle Initial)5. PATIENT S ADDRESS (No., Street)1a. INSURED S NUMBER (For Program In Item 1)3. PATIENT S BIRTH DATEMM DD YSEXMFCITYSTATEPICAZIP CODETELEPHONE (Include Area Code)( )4. INSURED S NAME (Last Name, First Name, Middle Initial)7. INSURED S ADDRESS (No., Street)CITYSTATEZIP CODETELEPHONE (Include Area Code)( )6. PATIENT RELATIONSHIP TO INSURED Self Spouse Child Other8.

1. medicare medicaid tricare champva group feca other champus health plan blk lung

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