Sample Health Insurance Claim Form

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 TRICARE 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 PROVIDER 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)
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. SERVICE FACILITY LOCATION INFORMATION
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
ID
QUAL..
RENDERING
PROVIDER ID. #
28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
$ $ $
33. BILLING PROVIDER INFO & PH # ( )
a.
b.
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
NUCC Instruction Manual available at: www.nucc.org
YES NO
pp
( )
If yes, return to and complete item 9 a-d.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
20. OUTSIDE LAB?
$ CHARGES
22. MEDICAID RESUBMISSION
23. PRIOR AUTHORIZATION NUMBER
MM DD YY
CARRIER
PATIENT AND INSURED INFORMATION
PHYSICIAN OR SUPPLIER INFORMATION
p
M
p p
p p
F
YES NO
YES NO
1. 3.
2. 4.
DATE(S) OF SERVICE
EMG
Place
of
Service
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS MODIFIER
DIAGNOSIS
POINTER
1500
F
M
SEX
MM DD YY
YES NO
YES
NO
YES NO
PLACE (State)
GROUP
HEALTH PLAN
FECA
BLK LUNG
p p
p p p p
p
Single Married Other
p p p
p p
p p
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
p p
p
p
Employed Full-Time Part-Time
Student Student
Self Spouse Child Other
(Medicare #) (Medicaid #) (Sponsor's SSN) (Medicaid #) (SSN or ID) (SSN) (ID)
p
p
p
p
p p
p
M
SEX
p
DAYS
OR
UNITS
EPSDT
Family
Plan
F. G. H. I. J.
24.
A. B. C. D.
E.
p p
OMB No. 1240-0044
Expires: 01/31/2016
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
17a.
17 b.
NPI
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
NPI
NPI
NPI
NPI
NPI
NPI
b.
a.
Page 1/4
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