Homecare Business

Manual Claim 1500

Insurer Or Billing Claim Number

Patient Name

PAYOR:

MEDICARE	TRICARE CAMPUS	CHAMVA	GROUP HEALTH PLAN	FECA BLK LUNG	BLUE SHIELD	BCBS	OTHER
(Medicaid #)	(ID)	(ID)	(ID)	(ID)	(ID)	(ID)	(Medicare #)

INSURED I.D. NUMBER

PATIENT'S NAME (Last First, MI)

Patient's Birth Date Sex

INSURED'S NAME (Last First, MI)

INSURED'S ADDRESS (Last First, MI)

Street

City

Zip

Phone

PATIENT RELATIONSHIP TO INSURED

Self
Spouse
Child
Other

RESERVED FOR NUCC USE (NO DATA ENTRY)

PATIENT'S ADDRESS (Last First, MI)

Street

City

Zip

Phone

OTHER INSURED'S NAME (Last First, MI)

A. OTHER INSURED'S POLICY OR GROUP #

B. RESERVED FOR NUCC USE

C. RESERVED FOR NUCC USE

D. INSURANCE PLAN NAME OR PROGRAM NAME

IS PATIENT'S CONDITION RELATED TO:

A. EMPLOYMENT?

Yes No

B. AUTO ACCIDENT?

Yes No

State

C. OTHER ACCIDENT?

Yes No

D. CLAIM CODES

INSURED'S POLICY GROUP OR FECA #

INSURED'S DATE OF BIRTH Sex

B. OTHER CLAIM ID

C. INSURANCE PLAN NAME OR PROGRAM NAME

D. IS THERE ANOTHER HEALTH BENEFIT PLAN?

Yes No If Yes, Complete 9, 9A And S0

PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE
READ BEFORE COMPLETING AND SINING

I Authorize The Release Of Any Medical Or Other Informacion Necessary To Process This Clai I Also Request Payment Of Government Benefits Either To Myself Or To The Sarty Who Accepes Assignment Below.

Yes No

DATE

INSURED'S OR AUTHORIZED PERSON'S SIGNATURE

I Authorize Payment Of Medical Benefits To The Undersigned Physician Or Supplier For Services Described Below

Yes No

NAME OF REFERRING PHYSICIAN OR OTHER SOURCE

A-B REFERRING/OTHER PHYSICIAN ID

17A-PIN

17B-PIN

HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

From

RESERVED FOR LOCAL USE

REMARKS

SELECT SPECIALTY OPTION IF APPLICABLE:

OUTSIDE LAB?

Yes No

$ CHARGES

RESUBMISSION CODE

ORIGINAL REF. NO.

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Bems A4. To Hem 246) ICD-10-CM

PRORAUTHORIZATION #

DATE(S) OF SERVICES

From

Comment

PLACE OF SERVICES

EMG

PROCEDURES, SERVICES, OR SUPPLIES CPT@

DAIG. POINTERS

DAYS OR UNITS

ID. QUAL

ID. QUAL
PIN
NPI

RENDERING # PROVIDER ID

EMG

FEDERAL TAX ID NUMBER

SSN EIN

PATIENT ACCOUNT #

ACCEPT ASSIGNMENT

SSN EIN

TOTAL CHARGES

AMOUNT PAID

RESERVED FOR NUCCUSE

SIGNATURE OF PHYSICIAN OR SUPPLIER

[LAST, FIRST. MIOOLE) . ICLUDINO DEGREES OR CREDENTIALS

TITLE

DATE

Service facility location info

NAME

Street

City

Zip

32A NPI

32B LEGACY

LEGACY ID QUALIRER

PATIENT'S ADDRESS (Last First, MI)

Name

Street

City

Zip

Phone

32A NPI

32B LEGACY

LEGACY ID QUALIRER

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Manual Claim 1500