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HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
1.    MEDICARE           MEDICAID              THICARE                       CHAMPVA             GROUP                      FECA                 OTHER —— i                       i —— ,                        , —— , CHAMPUS            , —— i                        , —— i HEALTH PLAN, —— , BLKLUNG, —— , J (Medicare ft)\       (Medlcaid i)         (Sponsor's SSN)           (Member IDit)        \tSSNorlD)                       \(ID)
	a. INSURED'S I.D. NUMBER
	(For Program in item 1)
	
2. PATIENT'S NAME (Last Name, First Name, Middle Init al)
	3. PATIENT'S BIRTH DATE                SEX 
MM   i     DD   i       YY         
	4. INSURED'S NAME (Last Name, First Name, Middle Initial)
	
5. PATIENT'S ADDRESS (No., Street)
	6. PATIENT RELATIONSHIP TO INSURED Self]     | Spouse]     | Child]     |    Otter]     |
	7. INSURED'S ADDRESS (No., Street)

CITY
	STATE
	8. PATIENT STATUS Single f"~|     Married]      |        Other]      |

 Full-Time i — i Part-Timei —— i Student   1     1 Student   1     1
	CITY
	STATE               
	
ZIP CODE
	TELEPHONE (Include Area Code)
	
	ZIP CODE                                     TELEPHONE (Include Area Code)                  
(     )                    
	
9. OTHER INSURED'S NAME (Last Name, First Name, Middle nitial)
	10. IS PATIENT'S CONDITION RELATED TO: a. EMPLOYMENT? (Current or Previous)
(  )YES   (  )NO
b. AUTO ACCIDENT?                        PLACE (state)
	1 1 . INSURED'S POLICY GROUP OR FECA NUMBER                                            
	
a. OTHER INSURED'S POLICY OR GROUP NUMBER
	
	INSURED'S DATE OF BIRTH
 MM   !    DD            YY

	SEX                               
	
b. OTHER INSURED'S DATE OF BIRTH            MM         DD           YY                                              3EA

	b. EMPLOYER'S NAME OR SCHOOL NAME                                                            
	
c. EMPLOYER'S NAME OR SCHOOL NAME
	c. OTHER ACCIDENT? (  )YES         (  )NO
	c. INSURANCE PLAN NAME OR PROGRAM NAME                                                
	
d. INSURANCE PLAN NAME OR PROGRAM NAME
	10d. RESERVED FOR LOCAL USE
	d. IS THERE ANOTHER HEALTH BENEFIT PLAN?                                                    YES (  )             NO (  )          If yes, return to and complete item 9 a-d.
	
READ BACK OF FORM BEFORE COMPLETING It SIGNING THIS FORM.
1 2. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE 1 authorize the release of any medical or other information necessary to process this claim, 1 also request payment of government benefits either to myself or to the party who accepts assignment below.
SIGNED                                                                                                                             DATE
	13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE 1 authorize payment of medical benefits to the undersigned physician or supplier for services described below.
SIGNED
	
14. DATE OF CURRENT:         1 ILLNESS (First symptom) OR                15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. MM   i     DO   i        YY       M INJURY (Accident) OR                                 GIVE FIRST DATE    MM   i    DD   i       YY |            |                      1 PREGNANCY(LMP)                                                                                    |            |
	16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION                i MM  ,     DD   r       YY                       MM   ,    DD i        YY              J FROM           I              I                              TO
	
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE                17a
	
	18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM  ,     DD    ,        YY                         MM   ,     DD            YY FROM           I              ••                              TO                          i

	17b
	NPI

19. RESERVED FOR LOCAL USE
	20. OUTSIDE LAB?                                       $ DYES      DNO     I
	CHARGES
	
21 . DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1 , 2, 3 or 4 to Item 24E by Line)            
1.                     2.                   3.                     4.	22. MEDICAID RESUBMISSION CODE                                        ORIGINAL REF. NO.

	23. PRIOR AUTHORIZATION NUMBER
	
24. A. DATE(S) OF SERVICE                                                                                             MM       DD        YY                                   	B. PLACE OF SERVICE	D. PROCEDURES, SERVICES
CPT/HCPCS                                               	E. DIAGNOSIS POINTER	
F.                         I $ CHARGES                	G.  DAYS OR           
UNITS  	J. RENDERING  PROVIDER  ID
(NPI).                    	

                                                                                                                      

                                                                                                               

                                                                                                                        	

                                                                                                                       

	

	

	

	

							

							

							

25. FEDERAL TAX I.D. NUMBER       SSN  (   )  EIN  (   )       	26. PATIENT'S ACCOUNT	 27. ACCEPT ASSIGNMENT?
 YES  (   )           NO  (   )	28. TOTAL CHARGE               	29. AMOUNT PAID  	30. BALANCE DUE               	
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (1 certify that the statements on the reverse apply to this bill and are made a part thereof.)	32. SERVICE FACILITY LOCATION INFORMATION	33. BILLING PROVIDER INFO& PH # (       )      
	
SIGNED

	DATE             	                                                                      

NUCC Instruction Manual available at: www.nucc.org