PLACE OF

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

a. INSURED’S DATE OF BIRTH	SEX

HEALTH INSURANCE CLAIM FORM

OTHER 1a. INSURED’S I.D. NUMBER	(For Program in Item 1)

1. MEDICARE

MEDICAID

TRICARE

CHAMPVA

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.	13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize

12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary	payment of medical benefits to the undersigned physician or supplier for

to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment	services described below.

below.

MM	DD	YY

15.OTHER DATE	MM	DD	YY

14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP)

From	To

MM      DD	YY	MM	DD

ACCEPT ASSIGNMEN

INCLUDING DEGREES OR CREDENTIALS

(I certify that the statements on the reverse

apply to this bill and are made a part thereof.)

SIGNED	DATE	SIGNED

MM	DD

YY

FROM	TO

MM	DD	YY	MM	DD	YY

MM	DD	YY	MM	DD	YY

CODE

ORIGINAL REF. NO.

$ CHARGES

25. FEDERAL TAX I.D. NUMBER	SSN EIN	26. PATIENT’S ACCOUNT NO.	27.(For govt. claims, see back) T?	28. TOTAL CHARGE	29. AMOUNT PAID	30. BALANCE DUE

PICA	PICA

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

ZIP CODE	TELEPHONE (Include Area Code)	ZIP CODE	TELEPHONE (Include Area Code)

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)	20. OUTSIDE LAB?	$ CHARGES

22. RESUBMISSION

CARRIER

PHYSICIAN OR SUPPLIER INFORMATION

(ID#/DoD#)

YES	NO	If yes, complete items 9, 9a and 9d.

YES	NO

D.PROCEDURES, SERVICES, OR SUPPLIES

(Explain Unusual Circumstances)

DIAGNOSIS

POINTER

M	F

MM	DD	YY

YES	NO

YES	NO

YES	NO	M	F

GROUP

HEALTH PLAN

FECA

BLK LUNG

3. PATIENT’S BIRTH DATE	SEX

5. PATIENT’S ADDRESS (No., Street)	6. PATIENT RELATIONSHIP TO INSURED	7. INSURED’S ADDRESS (No., Street)

CITY	STATE     8. RESERVED FOR NUCC USE	CITY	STATE

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)

b. RESERVED FOR NUCC USE	b. AUTO ACCIDENT?	PLACE (State) b. OTHER CLAIM ID (Designated by NUCC)

d. INSURANCE PLAN NAME OR PROGRAM NAME	10d. RESERVED FOR LOCAL USE	d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

Self	Spouse	Child	Other

(Medicare #)

(Medicaid #)

(Member ID#)

(ID#)

(ID#)

(ID#)

DAYS

OR

UNITS

F.

H.	I.

J.

24. A.	DATE(S) OF SERVICE

B.	C.

E.

PROVIDER ID. #

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE	17a.	18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

YY     SERVICE     EMG

RENDERING

31. SIGNATURE OF PHYSICIAN OR SUPPLIER	32. SERVICE FACILITY LOCATION INFORMATION

c. RESERVED FOR NUCC USE	c. OTHER ACCIDENT?	c. INSURANCE PLAN NAME OR PROGRAM NAME

71b. NPI	FROM	TO

SIGNED	DATE	a.	b.	a.	b.

1	NPI

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12

G.

EPSDT

Plan

ID.

Family     QUAL.

33. BILLING PROVIDER INFO & PH #      (	)

CPT/HCPCS	MODIFIER

(	)	(	)

2	NPI

3	NPI

4	NPI

5	NPI

6	NPI

YES	NO	$	$	$

PATIENT AND INSURED INFORMATION

NUCC Instruction Manual available at: www.nucc.org	PLEASE PRINT OR TYPE	APPROVED OMB-0938-1197 FORM CMS-1500 (02-12)

A.	B.	C.	D.

E.	F.	G.	H.	23. PRIOR AUTHORIZATION NUMBER

I.	J.	K.	L.

QUAL.

QUAL.

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY	Relate A-L to service line below (24E)      ICD Ind.