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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.

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Transcription of Health Insurance Program HEALTH INSURANCE CLAIM …

1 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.

2 PATIENT STATUS SingleMarriedOtherEmployedFull-TimePart- TimeStudentStudent9. OTHER INSURED S NAME (Last Name, First Name, Middle Initial)10. IS PATIENT S CONDITION RELATED TO: a. EMPLOYMENT? (Current or Previous)YESNOb. AUTO ACCIDENT? PLACE (State)YESNOc. OTHER ACCIDENT?YESNO11. INSURED S POLICY GROUP OR FECA NUMBERa. INSURED S DATE OF BIRTH MM DD YYSEXMFb. EMPLOYER S NAME OR SCHOOL NAMEc. INSURANCE PLAN NAME OR Program NAMEa. OTHER INSURED S POLICY OR GROUP NUMBERb. OTHER INSURED S BIRTH DATEMM DD YYSEXMFc. EMPLOYER S NAME OR SCHOOL NAMEd. INSURANCE PLAN NAME OR Program NAME10d. RESERVED FOR LOCAL USEd. IS THERE ANOTHER HEALTH BENEFIT PLAN?YESNOIf yes, return to and complete item 9 BACK OF FORM BEFORE COMPLETING & SIGNING THIS PATIENT S OR AUTHORIZED PERSON S SIGNATURE I authorize the release of any medical or other information necessaryto process this CLAIM .

3 I also request payment of government benefits either to myself or to the party who accepts INSURED S OR AUTHORIZED PERSON S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier forservices described DATE OF CURRENT:MM DD YYILLNESS (First symptom) ORINJURY(Accident) ORPREGNANCY (LMP)15. IF PATIENT HAS HAD SAME OR SIMILAR FIRST DATEMM DD YY16. DATES PATIENT UNABLE TO WORK IN CURRENT DD YYMM DD YYFROMTO18. HOSPITALIZATION DATES RELATED TO CURRENT DD YYMM DD YYFROMTO17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE17a. 17b. NPINPINPINPINPINPINPINPINPI19. RESERVED FOR LOCAL USE20. OUTSIDE LAB? $ CHARGESYESNO22.

4 MEDICAID RESUBMISSIONCODEORIGINAL REF. PRIOR AUTHORIZATION NUMBER21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1, 2, 3 OR 4 TO ITEM 24E BY LINE) ABCDEFGHIJDATE(S) OF SERVICEFrom ToMM DD YY MM DD YYPlaceofServiceEMGPROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)CPT/HCPCS MODIFIERDIAGNOSIS POINTER$ CHARGESDAYSORUNITSEPSDTF amilyPlanIDQUALRENDERING PROVIDER ID. #12345625. FEDERAL TAX NUMBER SSN EIN26. PATIENT S ACCOUNT ACCEPT ASSIGNMENT?(For govt. claims, see back)YES NO28. TOTAL CHARGE$29. AMOUNT PAID$30. BALANCE DUE$33. BILLING PROVIDER INFO & PH # ( )a. SERVICE FACILITY INFORMATIONa.

5 SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS(I certify that the statements on the reverse apply to this bill and are made a part thereof.)SIGNED DATENew York State Government Employees HEALTH INSURANCE ProgramHEALTH INSURANCE CLAIM FORMCARRIERPATIENT AND INSURED INFORMATIONPHYSICIAN OR SUPPLIER INFORMATIONNUCC Instruction Manual available at: OMB-0938-0999 FORM CMS-1500 (08/05)PICAX30500 EMPIRE PLAN1500 APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PLEASE MAIL CLAIMS TO: United HealthCare INSURANCE Company of New Box 1600 Kingston, New York 12402-16001-877-7 NYSHIP (1-877-769-7447) INSURANCE FRAUDS PREVENTION ACTThe following statement is printed pursuant to Regulation 95 of the New York State INSURANCE Department.

6 Any person who knowingly and with intent to defraud any INSURANCE company or other person files a statement of claimcontaining any materially false information, or conceals for the purpose of misleading, information concerning any factmaterial thereto, commits a fraudulent INSURANCE act, which is a crime, and shall also be subject to a civil penalty not toexceed five thousand dollars and the stated value of the CLAIM for each such violation.


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