Cms 1500

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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

Nowhere

ZIP CODE

TELEPHONE (Include Area Code)

22222

(

) N/A

Part-Time Student

22222

(

9. 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

F

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENTS OR AUTHORIZED PERSON’S SIGNATURE

13. INSUREDS OR AUTHORIZED PERSON’S SIGNATURE

.

SIGNED

FROM

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD YY TO

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

17a.

19. RESERVED FOR LOCAL USE

TY

17b.

NPI

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO 20. OUTSIDE LAB? $CHARGES

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. | 2. | 24. A. MM

N/A .

. .

3. |

N/A .

YES NO 22. MEDICADE RESUBMISSION CODE ORIGINAL REF. # 23. PRIOR AUTHORIZATION #

.

SI

N/A .

4. |

N/A .

. E. DIAGNOSIS POINTER
(1, 2, 3, or 4)

DATE(S) OF SERVICE From To DD YY MM

B.

C.

DD

YY

PLACE OF SERVICE

EMG

D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER

F. $ CHARGES

G.
DAYS OR UNITS

H.
EPSDT Family Plan

I.
ID. QUAL.

ER

NPI

NPI

NPI

UN IV

NPI 26. PATIENT’S ACCOUNT # 27. ACCEPT ASSIGNMENT?
(For govt. claims, see back)

25. FEDERAL TAX I.D. #

SSN EIN

28. TOTAL CHARGE $

29. AMOUNT PAID $

YES 32. SERVICE FACILITY LOCATION INFORMATION

NO

31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS

33. BILLING PROVIDER INFO & PH #

(

SIGNED

DATE

a.

b.

a.

b.

IX
STATE

NY

) N/A

SEX

F

.

J. PROVIDER ID. #

30. BALANCE DUE $

)

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