APPROVED OMB-0938-1197 FORM 1500 (02-12) 1a. INSURED’S I.D. NUMBER (For Program in Item 1) 4. INSURED’S NAME (Last Name, First Name, Middle Initial)...
PLEASE MAIL CLAIMS TO: United HealthCare Insurance Company of New York P.O. Box 1600 Kingston, New York 12402-1600 1-877-7NYSHIP (1-877-769-7447)
PICA B. PLACE OF SERVICE 1a. INSURED’S I.D. NUMBER (For Program in Item 1) 4. INSURED’S NAME (Last Name, First Name, Middle Initial) 7. INSURED’S ADDRESS (No
Payee NRIC: Bank Account No:: Notification of payment will be sent to this email address. Important Notice: The Company shall (i) be discharged from all liability
If you received a service in: Return your form to: Alabama Cahaba GBA Medicare Part B Claims P.O. Box 6169 Indianapolis, IN 46206 Alaska Noridian Healthcare Solutions
National Health Insurance Company – Daman ... Reimbursement Claim Form ... healthcare services provided to me during the period of my insurance coverage with Daman
CONTINENTAL AMERICAN INSURANCE COMPANY CLAIM FORM Post Office Box 427 Email: [email protected] . Columbia, South Carolina 29202 Phone (800)433-3036 Fax (803)799-7737
Enrollment Form Thank you for choosing a Blue Cross Blue Shield plan. Please take a few minutes to help us set up your membership by filling out the attached
CONTINENTAL AMERICAN INSURANCE COMPANY CLAIM FORM Post Office Box 427 • Columbia, South Carolina 29202 • Phone (800) 433-3036 Fax (866) 849-2970
Payee NRIC: Bank Account No:: Notification of payment will be sent to this email address. Important Notice: The Company shall (i) be discharged from all liability
BORANG TUNTUTAN INSURANS PERJALANAN ... Alamat Surat Menyurat ... Pembatalan Perjalanan Medical report Laporan perubatan
c) The damaged vehicle must be parked at safe place to avoid any subsequent damage/loss. Bajaj Allianz General Insurance ... Statement to describe circumstances leading to an accident \ theft [please also specifically mention the location of accident
Income Details of Claimant PPS No. Please enter details of income that was subject to PAYE in the year of claim. These details are available on your Form P60 or, if
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Group life claim fraud statements Alaska:A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim
BENEFIT TYPE: PLEASE ENCLOSE THE FOLLOWING ITEMS WITH THE ABOVE CLAIM FORM: Prescription Drugs All itemized Prescription drug receipts from your pharmacist
SUBSCRIBER INFORMATION Primary Participant ID# (required) Company Employee Number (if appropriate) Plan Sponsor Last Name First Name Middle Initial
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Aetna International Claim Form . Please submit this completed claim form with itemized bills and receipts. A separate claim form is needed for each family
P M A S PLEASE PRINT OR TYPE
E L
APPROVED OMB-0938-1197 FORM 1500 (02-12)
P M A S PLEASE PRINT OR TYPE
E L
APPROVED OMB-0938-1197 FORM 1500 (02-12)
CARRIER
HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 PICA
PICA TRICARE
CHAMPVA
(ID#/DoD#)
(Member ID#)
GROUP HEALTH PLAN (ID#)
FECA BLK LUNG (ID#)
3. PATIENT’S BIRTH DATE DD YY MM
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
(ID#)
5. PATIENT’S ADDRESS (No., Street)
F
6. PATIENT RELATIONSHIP TO INSURED
CITY
STATE
8. RESERVED FOR NUCC USE
STATE
CITY
TELEPHONE (Include Area Code)
(
7. INSURED’S ADDRESS (No., Street)
Other
Child
Spouse
Self
ZIP CODE
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
SEX M
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 MM DD YY
b. RESERVED FOR NUCC USE
b. AUTO ACCIDENT?
PLACE (State)
c. OTHER ACCIDENT?
c. INSURANCE PLAN NAME OR PROGRAM NAME NO
YES d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. CLAIM CODES (Designated by NUCC)
d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES
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 to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.
15. OTHER DATE
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
17a.
QUAL.
MM
DD
YY
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION YY MM DD MM DD YY TO FROM 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES YY MM DD MM DD YY TO FROM
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) B.
C.
D.
E.
F.
G.
H.
MM
YY
B. C. PLACE OF SERVICE EMG
NO
22. RESUBMISSION CODE
ICD Ind.
A.
J.
$ CHARGES
20. OUTSIDE LAB? YES
DATE(S) OF SERVICE From To DD YY MM DD
If yes, complete items 9, 9a and 9d.
SIGNED
17b. NPI
I. 24. A.
NO
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below.
DATE
SIGNED 14. DATE OF CURRENT ILLNESS, INJURY or PREGNANCY (LMP) MM DD YY QUAL.
F
b. OTHER CLAIM ID (Designated by NUCC)
NO
YES c. RESERVED FOR NUCC USE
SEX M
NO
YES
ORIGINAL REF. NO.
23. PRIOR AUTHORIZATION NUMBER
K. L. D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER
E. DIAGNOSIS POINTER
F.
H.
G.
$ CHARGES
I.
J. RENDERING PROVIDER ID. #
EPSDT ID. Family Plan QUAL.
DAYS OR UNITS
1
NPI
2
NPI
3
NPI
4
NPI
5
NPI
6
NPI
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT’S ACCOUNT NO.
27. ACCEPT ASSIGNMENT? (For
govt. claims, see back)
YES 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.)
SIGNED
DATE
NO
32. SERVICE FACILITY LOCATION INFORMATION
a.
NUCC Instruction Manual available at: www.nucc.org
