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MDCodeWizard.com HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 PICA
(Medicare #)
MEDICAID
TRICARE
CHAMPVA
(Medicaid #)
(ID#/DoD#)
(Member ID#)
GROUP HEALTH PLAN (ID#)
3. PATIENT’S BIRTH DATE MM DD YY
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
OTHER
FECA BLK LUNG (ID#)
CITY
STATE
ZIP CODE
F
6. PATIENT RELATIONSHIP TO INSURED Self
Spouse
Child
7. INSURED’S ADDRESS (No., Street)
Other
8. RESERVED FOR NUCC USE
STATE
CITY
TELEPHONE (Include Area Code)
(
(For Program in Item 1)
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
SEX M
5. PATIENT’S ADDRESS (No., Street)
1a. INSURED’S I.D. NUMBER
(ID#)
TELEPHONE (Include Area Code)
ZIP CODE
(
)
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT’S CONDITION RELATED TO:
a. OTHER INSURED’S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (Current or Previous)
b. RESERVED FOR NUCC USE
b. AUTO ACCIDENT?
c. RESERVED FOR NUCC USE
c. OTHER ACCIDENT?
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
)
11. INSURED’S POLICY GROUP OR FECA NUMBER
a. INSURED’S DATE OF BIRTH YY MM DD
SEX
NO
YES
F
M
PLACE (State)
b. OTHER CLAIM ID (Designated by NUCC)
NO
YES
c. INSURANCE PLAN NAME OR PROGRAM NAME NO
YES
d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES
PATIENT AND INSURED INFORMATION
1. MEDICARE
PICA
If yes, complete items 9, 9a and 9d.
NO
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. DATE
14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP) MM DD YY
15.OTHER DATE
SIGNED MM
DD
YY
QUAL.
QUAL. 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
17a.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD YY TO FROM 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO
71b. NPI 19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)
YES 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
F.
E. I. 24. A. MM
Relate A-L to service line below (24E)
B.
A.
J. DATE(S) OF SERVICE From To YY MM DD DD
YY
B.
C.
PLACE OF SERVICE
EMG
$ CHARGES
20. OUTSIDE LAB? 22. RESUBMISSION CODE
ICD Ind.
C.
D.
G.
H.
K. L. D.PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER
NO ORIGINAL REF. NO.
23. PRIOR AUTHORIZATION NUMBER
E. DIAGNOSIS POINTER
F. $ CHARGES
G.
H.
I.
DAYS OR UNITS
EPSDT Family Plan
ID. QUAL.
1
J. RENDERING PROVIDER ID. #
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
NO
28. TOTAL CHARGE $
29. AMOUNT PAID $
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.)
32. SERVICE FACILITY LOCATION INFORMATION
33. BILLING PROVIDER INFO & PH #
SIGNED
a.
a.
DATE
NUCC Instruction Manual available at: www.nucc.org
