Health Insurance Claim Form Sample
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., Street)
CITY STATE
ZIP CODE TELEPHONE (INCLUDE AREA CODE)
11. INSURED’S POLICY GROUP OR FECA NUMBER
a. INSURED’S DATE OF BIRTH
b. EMPLOYER’S NAME OR SCHOOL NAME
c. INSURANCE PLAN NAME OR PROGRAM NAME
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize
payment of medical benefits to the undersigned physician or supplier for
services described below.
SEX
F
HEALTH INSURANCE CLAIM FORM
OTHER
1. MEDICARE MEDICAID CHAMPUS CHAMPVA
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.
SIGNED DATE
ILLNESS (First symptom) OR
INJURY (Accident) OR
PREGNANCY(LMP)
MM DD YY
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
GIVE FIRST DATE
MM DD YY
14. DATE OF CURRENT:
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
19. RESERVED FOR LOCAL USE
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
17a. I.D. NUMBER OF REFERRING PHYSICIAN
From
MM DD YY
To
MM DD YY
1
2
3
4
5
6
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?
(For govt. claims, see back)
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
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
RENDERED (If other than home or office)
SIGNED
MM DD YY
FROM TO
FROM TO
MM DD YY
MM DD YY
MM DD YY
MM DD YY
CODE ORIGINAL REF. NO.
$ CHARGES EMG
COB
RESERVED FOR
LOCAL USE
28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
$$$
33. PHYSICIAN’S, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE
& PHONE #
PIN# GRP#
PICA
PICA
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
5. PATIENT’S ADDRESS (No., Street)
CITY STATE
ZIP CODE TELEPHONE (Include Area Code)
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
a. OTHER INSURED’S POLICY OR GROUP NUMBER
b. OTHER INSURED’S DATE OF BIRTH
c. EMPLOYER’S NAME OR SCHOOL NAME
d. INSURANCE PLAN NAME OR PROGRAM NAME
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
YES NO
( )
If yes
, return to and complete item 9 a-d.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
20. OUTSIDE LAB? $ CHARGES
22. MEDICAID RESUBMISSION
23. PRIOR AUTHORIZATION NUMBER
MM DD YY
CARRIER
PATIENT AND INSURED INFORMATION
PHYSICIAN OR SUPPLIER INFORMATION
M
F
YES NO
YES NO
1. 3.
2. 4.
DATE(S) OF SERVICE
Type
of
Service
Place
of
Service
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS MODIFIER
DIAGNOSIS
CODE
PLEASE
DO NOT
STAPLE
IN THIS
AREA
F
M
SEX
MM DD YY
YES NO
YES NO
YES NO
PLACE (State)
GROUP
HEALTH PLAN
FECA
BLK LUNG
Single Married Other
3. PATIENT’S BIRTH DATE
6. PATIENT RELATIONSHIP TO INSURED
8. PATIENT STATUS
10. IS PATIENT’S CONDITION RELATED TO:
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
b. AUTO ACCIDENT?
c. OTHER ACCIDENT?
10d. RESERVED FOR LOCAL USE
Employed Full-Time Part-Time
Student Student
Self Spouse Child Other
(Medicare #) (Medicaid #) (Sponsor’s SSN) (VA File #) (SSN or ID) (SSN) (ID)
( )
M
SEX
DAYS
OR
UNITS
EPSDT
Family
Plan
FGHIJK24. A B C D E
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), FORM RRB-1500,
FORM OWCP-1500
APPROVED OMB-0938-0008
Page 1/2
Free Download
Health Insurance Claim Form Sample PDF
Favor this template? Just fancy it by voting!
(0 Votes)
0.0
Related Forms
2 Page(s) | 1633 Views | 16 Downloads
2 Page(s) | 1089 Views | 3 Downloads
