1500 State Form Task

 1500 Claim Form Task Essay

Appendix C

MEDICAID

(Medicaid #)

TRICARE

CHAMPUS

(Sponsor's SSN)

CHAMPVA

(Member IDENTIFICATION #)

2 . PATIENT'S TERM (Last Name, First Identity, MI)

GROUP

HEALTH STRATEGY

(SSN or ID)

FECA

BLK LUNG

(SSN)

several. PATIENT'S BDAY

MM

DD

YY

Doe, Katherine

01

01

five. PATIENT'S ADDRESSES ( #, Street)

5555 Noname Court docket

CITY

STATE

Nowhere

NEW YORK

ZIP CODE

TELEPHONE (Include Area Code)

22222

(

OTHER

1a. INSURED'S I. D. #

(ID)

999000666

SEX

Meters

4. INSURED'S NAME (Last Name, First Name, MI)

F

Doe, James

1950

6. INDIVIDUAL RELATIONSHIP TO INSURED

several. INSURED'S ADDRESS ( #, Street)

Home

Spouse

8. PATIENT STATUS

CITY

Sole

Child

2222 Noname Court docket

Other

Hitched

Nowhere

Additional

ZIP CODE

Employed

)

9. DIFFERENT INSURED'S IDENTITY (Last Brand, First Name, MI)

A lot of the time

Student

Part-Time

Student

(

MM

DD

YY

M

MM

PLACE (State)

CERTAINLY

F

a. INSURED'S DAY OF DELIVERY

NO

m. AUTO ACCIDENT?

SEXUAL INTERCOURSE

c. OTHER ACCIDENT?

g. INSURANCE PLAN NAME OR SOFTWARE NAME

10d. LOCAL MAKE USE OF

DD

d. HEALTH GAIN PLAN?

16. DATE OF CURRENT:

LOGISTIK

DD

YY

ILLNESS (First symptom) OR PERHAPS

INJURY (Accident) OR

PREGNANCY (LMP)

twenty-one. DIAGNOSIS OR PERHAPS NATURE OF ILLNESS OR PERHAPS INJURY

V70. 0

.

twenty four. A.

.

DATE(S) OF SERVICES

From

To

DD

YY

MM

some.

DD

YY

ESTE

IV

MM

.

3.

25. GOVERNMENT TAX My spouse and i. D. #

.

SSN DAS

B.

C.

PLACE

OF

SERVICE

EMG

.

F

personal unsecured on record

20. OUTSIDE THE HOUSE LAB?

$CHARGES

YES

ZERO

22. MEDICADE RESUBMISSION

CODE

ORIGINAL REF. #

.

twenty-three. PRIOR CONSENT #

.

G. PROCEDURES, COMPANIES, OR PRODUCTS

(Explain Uncommon Circumstances)

CPT/HCPCS

MODIFIER

Electronic.

DIAGNOSIS

POINTER

F.

G.

H.

My spouse and i.

J.

dollar CHARGES

DAYS AND NIGHTS

OR

DEVICES

EPSDT

Family

Plan

IDENTITY.

QUAL.

COMPANY ID. #

(1, two, 3, or 4)

NPI

NPI

NPI

NPI

21. PATIENT'S BANK ACCOUNT #

28. ACCEPT ASSIGNMENT?

28. TOTAL...

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