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HEALTH INSURANCE CLAIM FORM
APPROVEDBYNATIONALUNIFORMCLAIMCOMMITTEE(NUCC)02/12
PICA
PICA
2.PATIENT’S NAME (Last Name, First Name, Middle Initial)
3.PATIENT’S BIRTH DATE
MMDDYY
M
SEX
OTHER
(ID#)
F
1a. INSURED’S I.D.NUMBER(For Program in Item1)
4. INSURED’S NAME (Last Name, First Name, MiddleInitial)
5.PATIENT’S ADDRESS (No., Street)
CITYSTATE
ZIP CODETELEPHONE (Include AreaCode)
6.PATIENT RELATIONSHIP TO INSURED SelfSpouseChildOther
8. RESERVED FOR NUCCUSE
7. INSURED’S ADDRESS (No., Street)
CITYSTATE
ZIP CODETELEPHONE (Include AreaCode)
()()
9.OTHER INSURED’S NAME (Last Name, First Name, MiddleInitial)
10.IS PATIENT’S CONDITION RELATED TO:
11.INSURED’S POLICY GROUP OR FECA NUMBER
a.OTHER INSURED’S POLICY OR GROUPNUMBER
a. EMPLOYMENT? (Current orPrevious)
YESNO
a.INSURED’S DATE OFBIRTH
MMDDYY
SEX
MF
b.RESERVED FOR NUCCUSE
b. AUTOACCIDENT?
PLACE (State)
b.OTHER CLAIM ID (Designated byNUCC)
c.RESERVED FOR NUCCUSE
d.INSURANCE PLAN NAME OR PROGRAMNAME
YESNO
c. OTHER ACCIDENT?
YESNO
10d. RESERVED FOR LOCAL USE
c. INSURANCE PLAN NAME OR PROGRAM NAME
d. IS THERE ANOTHER HEALTH BENEFITPLAN?
YESNO
If yes, complete items 9, 9a and9d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other informationnecessary
to process this claim. I also request payment of government benefits either to myself or to the party who acceptsassignmentbelow.
SIGNEDDATE
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below.
SIGNED
14.DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY(LMP) MMDDYY
15.OTHERDATE
MMDDYY
16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MMDDYYMMDDYY
QUAL.QUAL.
17.NAME OF REFERRING PROVIDER OR OTHER SOURCE17a.
71b. NPI
FROMTO
18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MMDDYYMMDDYY
FROMTO
19. ADDITIONAL CLAIM INFORMATION (Designated byNUCC)
20. OUTSIDE LAB?$CHARGES
21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURYRelate A-L to service line below(24E)
ICDInd.
YESNO
22.RESUBMISSION
CODEORIGINAL REF. NO.
A.B.
E.F.
I.J.
C.D.
G.H.
K.L.
23.PRIOR AUTHORIZATION NUMBER
24.A.
DATE(S) OF SERVICE
B.C.
D.PROCEDURES, SERVICES, ORSUPPLIESE.
F.G.
H.I.J.
From
ToPLACE OF
(Explain Unusual Circumstances)
DIAGNOSIS
DAYS OR
EPSDT
Family
ID.
RENDERING
MM DDYY
1
2
3
4
5
6
MMDDYY
SERVICE
EMG
CPT/HCPCS
MODIFIER
POINTER
$ CHARGES
UNITS
Plan
QUAL.
NPINPINPINPINPI
NPI
PROVIDER ID. #
25.FEDERAL TAX I.D. NUMBERSSNEIN26. PATIENT’S ACCOUNTNO.27. ACCEPTASSIGNMENT?
(For govt. claims, seeback)
28.TOTAL CHARGE29. AMOUNT PAID30. BALANCE DUE
YESNO$$$
31.SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.)
SIGNEDDATE
32.SERVICE FACILITY LOCATION INFORMATION33. BILLING PROVIDER INFO & PH # ()
a.b.a.b.
NUCC Instruction Manual available at:
PLEASE PRINT ORTYPE
APPROVED OMB-0938-1197 FORM CMS-1500(02-12)