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CARRIER
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid #) (ID#/DoD#) (Member ID#) (ID#) (ID#) (ID#)
2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
MM DD YY
M F
5. PATIENT’S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
Self Spouse Child Other
CITY STATE
CITY STATE
PATIENT AND INSURED INFORMATION
8. RESERVED FOR NUCC USE
ZIP CODE
TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
( ) ( )
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER
a. OTHER INSURED’S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX
MM DD YY
YES NO M F
b. RESERVED FOR NUCC USE
b. AUTO ACCIDENT? PLACE (State) b. OTHER CLAIM ID (Designated by NUCC)
YES NO
c. RESERVED FOR NUCC USE c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, complete items 9, 9a and 9d.
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 information necessary 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment payment of medical benefits to the undersigned physician or supplier for
below. services described below.
SIGNED DATE
SIGNED
14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP) 15. OTHER DATE 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD YY MM DD YY MM DD YY MM DD YY
QUAL. QUAL. FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM DD YY MM DD YY
71b. NPI FROM TO
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)
20. OUTSIDE LAB? $ CHARGES
YES NO
21. DIAGNOSIS OR NATURE OF ICD Ind. 22. RESUBMISSI
ON ORIGINAL REF. NO.
ILLNESS OR INJURY Relate A-L to service line below (24E) CODE
A. B.
C. D.
E. F.
G. H. 23. PRIOR AUTHORIZATION NUMBER
I. J.
K. L.
24.
PHYSICIAN OR SUPPLIER INFORMATION
DATE(S) OF SERVICE B. C. D.PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
A.
From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSDT ID. RENDERING
MM DD YY OR Family
MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS Plan QUAL. PROVIDER ID. #
1
NPI
2
NPI
3
NPI
4
NPI
5
NPI
6
NPI
25. FEDERA
26. PATIENT’S ACCOUNT
27. ACCEPT
28. TOTAL 29. AMOUNT 30. BALANCE DUE
L TAX I.D. NUMBER SSN EIN ASSIGNMENT?
NO. (For govt. claims, see back) CHARGE PAID
YES NO $
$ $
31. SIGNATURE OF PHYSICIAN OR
32. 33.
SUPPLIER INCLUDING DEGREES OR
SERVICE FACILITY LOCATION BILLING PROVIDER INFO & PH # (
CREDENTIALS (I certify that the statements INFORMATION
on the reverse apply to this bill and are made )
a part thereof.)
SIGNED DATE a. b.
a. b.
NUCC Instruction Manual available at: www.nucc.org PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM CMS-1500 (02-12)
