SAMPL E - CMS

1 SAMPLEAPPROVED OMB-0938-1197 FORM 1500 (02-12) PLEASE PRINT OR TYPESAMPLEAPPROVED OMB-0938-1197 FORM 1500 (02-12) PLEASE PRINT OR TYPEAPPROVED OMB-0938-1197 FORM 1500 (02-12) 1a. 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 CODE TELEPHONE (Include Area Code)11. INSURED S POLICY GROUP OR FECA NUMBERa. INSURED S DATE OF BIRTHb. 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 MEDICAID TRICARE CHAMPVAREAD 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.

2 I also request payment of government benefits either to myself or to the party who accepts DATEMM DD YY15. OTHER DATEMM DD YY14. DATE OF CURRENT19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E)FromMM DD YYToMM DD YY12345625. FEDERAL TAX NUMBER SSN EIN 26. PATIENT S ACCOUNT NO. 27. 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. $ $PICAPICA2. PATIENT S NAME (Last Name, First Name, Middle Initial)5. PATIENT S ADDRESS (No., Street)CITYSTATEZIP CODE TELEPHONE (Include Area Code)9. OTHER INSURED S NAME (Last Name, First Name, Middle Initial)a. OTHER INSURED S POLICY OR GROUP NUMBERb. RESERVED FOR NUCC USEc. RESERVED FOR NUCC USEd. INSURANCE PLAN NAME OR PROGRAM NAMEYES NO ( )If yes, .16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES20. OUTSIDE LAB?$ CHARGES22. RESUBMISSION23. PRIOR AUTHORIZATION NUMBERCARRIERPATIENT AND INSURED INFORMATIONPHYSICIAN OR SUPPLIER INFORMATIONM FYES NOYES NO DATE(S) OF SERVICEPLACE OFSERVICEPROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)CPT/HCPCS MODIFIERDIAGNOSISPOINTER FMSEXMM DD YY YES NO YES NO YES NOPLACE (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. CLAIM CODES (Designated by NUCC) Self Spouse Child Other ( ) ID. #117. NAME OF REFERRING PROVIDER OR OTHER SOURCE7a. EMGRENDERING32. SERVICE FACILITY LOCATION INFORMATION33. BILLING PROVIDER INFO & PH #NUCC Instruction Manual available at: INSURANCE PLAN NAME OR PROGRAM NAME17b. NPI BY NATIONAL UNIFORM CLAIM ( )PLEASE PRINT OR for NUCC Use ICD Ind. ILLNESS, INJURY or PREGNANCY (LMP) (NUCC)complete items 9, 9a and 9d 02/12 OTHER (Medicare#) (ID#) (ID#) (ID#) (Medicaid#) (ID#/Do) (Member ID#)D#