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Medicare
�� HEALTH INSURANCE CLAIM FORM
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MEDICARE
1.
□
MEDICAID
(Medicare#) D (Medicaid#)
DOE, JANE
TRICARE
(ID#/DoD#)
2. PATIENTS NAME (Last Name, First Name, Middle Initial)
□
Chicago CITY
60015
I
ZIP CODE
CHAMPVA
(MerrtJer ID#)
I
1111 FAKE ROAD
5. PATIENTS ADDRESS (No., Street)
□
GROUP HEALTH PLAN (ID#)
□
FECA BL.KLUNG (ID#)
12 31 1911
3. PATIENT'S BIRTH DATE MM I DD I YY 1 1 M
in
□ □ □
00
SEX
LBE907215904
(ID#)
IL
STATE
Spouse
Child
8. RESERVED FOR NUCC USE
)
DOE, JANE
Foo
7. INSURED'S ADDRESS (No., Street)
1111 FAKE ROAD
Other[i]
Chicago
-
10. IS PATIENTS 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 d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. CLAIM CODES (Designated by NUCC)
DYES
14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP) MM I DD I YY I I I QUALi 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE I I
I 19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)
Z853
DATE
MM
17b. NPIj
I. I 24. A.
MM
DATE(S) OF SERVICE To From DD yy MM DD
J. I
yy
1 03 I 31 : 21 I 03 I 31 II 21 2 03:I 31 :I 21 I 03:I 31 :I 21 I 3 03 I1 31 II 21 I 03: 31 II 21 I 4 03 I1 31 II 21 I 03: 31 II 21 I 5 03 :I 31 :I 21 I 03:I 6 I 620870864
11
I 11 I 11 I 31 : 21 I 11 I
25. FEDERAL TAX I.D. NUMBER
□ 00 SSN EIN
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.)
Doctor Name
SIGNED
119380
DATE
I I
I 19371 I
RT
LT
50
I
28967Z66354
26. PATIENTS ACCOUNT NO.
E. DIAGNOSIS POINTER
A
NUCC Instruction Manual available at: www.nucc.org
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PLEASE PRINT OR TYPE
H.
202112911
2576: 461 2 2576: 4611 2611:2111
14429192
28. TOTAL CHARGE
EPS01
OR UNITS
I
or govt. da[Jsee bac
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G.
20211291
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Plastic Surgery Hospital Inpatient 111 Fake Road Chicago, IL 60015 r'II
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ORIGINAL REF. NO.
DAYS
$CHARGES
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32. SERVICE FACILITY LOCATION INFORMATION
a.
F.
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1 [IDYES
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23. PRIOR AUTHORIZATION NUMBER
:
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$CHARGES
I
[ID No
22. RESUBMISSION CODE
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Siqna ture on File
DYES
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18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES yy DD I MM DD MM yy I I I TO FROM
H. I
1 19390
I
yy
D. I
I 11970 I RT I 11970 I LT
11
SIGNED
ICD Ind.: Q I I
K. I L I B. D. PROCEDURES, SERVICES, OR SUPPLIES C. PIACEOF (Explain Unusual Circumstances) I CPT/HCPCS MODIFIER SERVK:E EMG I I I I I I I I
a:
ff yes, complete items 9, 9a, and 9d.
[ID No
20. OUTSIDE LAB?
G.I
F. I
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16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION yy DD I MM yy DD MM I I I TO FROM I
1
C. I
B. I
E. I
DD I I
C SEX
services described below.
17a. � - -- -------------------------
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) A. I
I
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payment of medical benefits to the undersigned physician or supplier for
07/26/21
15. OTHER DATE I QUALi I
a:
0
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
Sig:na ture on File
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d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release ot any medical or other information necessary
SIGNED
0
BCBS OF TN
OONo
DYES
-
1 z
STATE
TELEPHONE (Include Area Code)
a. lNSURED'S DATE OF BIRTH MM DD I yy I M I oo I I b. OTHER CLAIM ID (Designated by NUCC) I I I c. INSURANCE PLAN NAME OR PROGRAM NAME
PLACE (State) OONO [_J
DYES c. OTHER ACCIDENT?
IL
6001 ( ) 11. INSURED'S POLICY GROUP OR FECA NUMBER 5 125188
[ID No
DYES
I
CITY
ZIP CODE
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
below.
(For Program in Item 1)
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
6. PATIENT RELATIONSHIP TO INSURED Self
PICAlfT
OTHER 1a. INSURED'S I.D. NUMBER
TELEPHONE (Include Area Code)
(
+ (.)
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
IT7PICA
Plan
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I. ID.
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123456789
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30. Rsvd for NUCC Use
Plastic Surgery Office 113 Fake Road Chicago, IL 60015
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NPI
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NPI
29. AMOUNT PAID
1 $ $ 33. BILLING PROVIDER INFO & PH#
J. RENDERING PROVIDER ID. #
QUAL.
lb. APPROVED OMB-0938-1197 FORM 1500 (02-12)