Transcription of MDCodeWizard
1 OFSERVICE1a. 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 CODETELEPHONE (Include Area Code)11. INSURED S POLICY GROUP OR FECA NUMBER a. INSURED S DATE OF BIRTHb. OTHER CLAIM ID (Designated by NUCC)d. 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 INSURANCE CLAIM FORMOTHER1. MEDICARE MEDICAIDTRICARECHAMPVAREAD BACK OF FORM BEFORE COMPLETING & SIGNING THIS PATIENT S OR AUTHORIZED PERSON S SIGNATURE I authorize the release of any medical or other information necessary to process this claim.
2 I also request payment of government benefits either to myself or to the party who accepts DATEMM DD DATEMM DD YY14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP)19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E)FromMMDDYYToMMDDYY12345625. FEDERAL TAX NUMBER SSN EIN26. PATIENT S ACCOUNT ACCEPT ASSIGNMENT?(For govt. claims, see back)31. SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS(I certify that the statements on the reverseapply to this bill and are made a part thereof.)SIGNEDDATESIGNEDMM DD YYFROMTOFROMTOMM DD YYMM DD YYMM DD YYMM DD YYCODE ORIGINAL REF.
3 NO.$ CHARGES28. TOTAL CHARGE29. AMOUNT PAID30. BALANCE DUE$$PICA2. PATIENT S NAME (Last Name, First Name, Middle Initial)5. PATIENT S ADDRESS (No., Street)CITYSTATEZIP CODE TELEPHONE (Include Area Code)9. OTHER INSURED S NAME (Last Name, First Name, Middle Initial)a. OTHER INSURED S POLICY OR GROUP NUMBERb. RESERVED FOR NUCC USEc. RESERVED FOR NUCC USEd. INSURANCE PLAN NAME OR PROGRAM NAMEYES NO()If yes, complete items 9, 9a and DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES20. OUTSIDE LAB?$ CHARGES22. RESUBMISSION23. PRIOR AUTHORIZATION NUMBERCARRIERPHYSICIAN OR SUPPLIER INFORMATION(ID#/DoD#)MFYES NOYES NODATE(S) OF , SERVICES, OR SUPPLIES(Explain Unusual Circumstances)CPT/HCPCSDIAGNOSISPOINTER FMSEXMM DD YYYESNOYESNOYESNOPLACE (State)GROUPHEALTH PLANFECABLK LUNG3.
4 PATIENT S BIRTH DATE6. PATIENT RELATIONSHIP TO INSURED8. RESERVED FOR NUCC USE 10. IS PATIENT S CONDITION RELATED TO:a. EMPLOYMENT? (Current or Previous)b. AUTO ACCIDENT?c. OTHER ACCIDENT?10d. RESERVED FOR LOCAL USESelf Spouse Child Other(Medicare #)(Medicaid #)(Member ID#)(ID#)(ID#) (ID#)( ID. #17. NAME OF REFERRING PROVIDER OR OTHER SERVICE FACILITY LOCATION INFORMATION33. BILLING PROVIDER INFO & PH #NUCC Instruction Manual available at: INSURANCE PLAN NAME OR PROGRAM BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02 ()APPROVED OMB-0938-1197 FORM CMS-1500 (02-12) )NPINPINPINPINPI$PATIENT AND INSURED PRINT OR Ind.
