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. 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.
2 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. 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.
3 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. 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.
