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L E. P. AM. S. PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12). L E. P. AM. S. PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12). CARRIER. HEALTH INSURANCE Claim FORM. APPROVED BY National Uniform Claim Committee (NUCC) 02/12. PICA PICA. 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S NUMBER (For Program in Item 1). HEALTH PLAN BLK LUNG. (Medicare#) (Medicaid#) (ID#/DoD#) (Member ID#) (ID#) (ID#) (ID#). 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial). MM DD YY. M F. 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street). Self Spouse Child Other CITY STATE 8. RESERVED FOR NUCC USE CITY STATE. PATIENT AND INSURED INFORMATION. ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code). ( ) ( ). 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10.

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE G. 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 …

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