Appendix C. 1a Feasibility Study

Appendix C
1. MEDICARE (Medicare #) MEDICAID (Medicaid #) TRICARE CHAMPUS (Sponsor’s SSN) CHAMPVA (Member ID #) GROUP HEALTH PLAN (SSN or ID) FECA BLK LUNG (SSN) OTHER (ID) SEX M 1a. INSURED’S I.D. # (For Program in Item 1)

999000666
4. INSURED’S NAME (Last Name, First Name, MI) F

2. PATIENT’S NAME (Last Name, First Name, MI)

Doe, Katherine
5. PATIENT’S ADDRESS ( #, Street)

3. PATIENT’S BIRTH DATE MM DD YY

01

01

1950
Child Other

Doe, James
7. INSURED’S ADDRESS ( #, Street)

6. PATIENT RELATIONSHIP TO INSURED Self Spouse 8. PATIENT STATUS Single Employed

CITY

STATE

PH O EN
CITY

1111 Noname Court
Nowhere
ZIP CODE

1111 Noname Court

NY
TELEPHONE (Include Area Code)

Married Full-Time Student

Other
OTHER INSURED’S NAME (Last Name, First Name, MI)

10. IS PATIENT’S CONDITION RELATED TO:

11. INSURED’S POLICY GROUP OR FECA #

123456
MM

a. OTHER INSURED’S POLICY OR GROUP #

a. EMPLOYMENT? (Current of Previous) YES NO

a. INSURED’S DATE OF BIRTH DD YY

M

b. INSURED’S DATE OF BIRTH MM DD YY M c. EMPLOYER’S NAME OR SCHOOL NAME

SEX F

b. AUTO ACCIDENT? YES c. OTHER ACCIDENT? YES 10d. LOCAL USE NO NO

PLACE (State)

b. EMPLOYER’S NAME OR SCHOOL NAME

U.S Army Tricare
YES

c. INSURANCE PLAN NAME OR PROGRAM NAME

None
d. INSURANCE PLAN NAME OR PROGRAM NAME

d. HEALTH BENEFIT PLAN? NO

If yes, return to and complete item 9 a-d.

14. DATE OF CURRENT: MM DD YY

ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP)

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM DD YY

O

SIGNED

SIGNATURE ON FILE

DATE