Transcription of SAMPL E - NUCC
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SAMPL E - NUCC
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).
APPROVED OMB-0938-1197 FORM 1500 (02-12) 1a. INSURED’S I.D. NUMBER (For Program in Item 1) 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
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