1500 Claim Form Assignment
Appendix C
MEDICAID
(Medicaid #)
TRICARE
CHAMPUS
(Sponsor’s SSN)
CHAMPVA
(Member ID #)
2. PATIENT’S NAME (Last Name, First Name, MI)
GROUP
HEALTH PLAN
(SSN or ID)
FECA
BLK LUNG
(SSN)
3. PATIENT’S BIRTH DATE
MM
DD
YY
Doe, Katherine
01
01
5. PATIENT’S ADDRESS ( #, Street)
1111 Noname Court
CITY
STATE
Nowhere
NY
ZIP CODE
TELEPHONE (Include Area Code)
22222
(
OTHER
1a. INSURED’S I.D. #
(ID)
999000666
SEX
M
4. INSURED’S NAME (Last Name, First Name, MI)
F
Doe, James
1950
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED’S ADDRESS ( #, Street)
Self
Spouse
8. PATIENT STATUS
CITY
Single
Child
1111 Noname Court
Other
Married
Nowhere
Other
ZIP CODE
Employed
)
9. OTHER INSURED’S NAME (Last Name, First Name, MI)
Full-Time
Student
Part-Time
Student
(
MM
DD
YY
M
MM
PLACE (State)
YES
F
a. INSURED’S DATE OF BIRTH
NO
b. AUTO ACCIDENT?
SEX
c. OTHER ACCIDENT?
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. LOCAL USE
DD
d. HEALTH BENEFIT PLAN?
14. DATE OF CURRENT:
MM
DD
YY
ILLNESS (First symptom) OR
INJURY (Accident) OR
PREGNANCY (LMP)
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
V70.0
.
24. A.
.
DATE(S) OF SERVICE
From
To
DD
YY
MM
4. |
DD
YY
UN
IV
MM
.
3. |
25. FEDERAL TAX I.D. #
.
SSN EIN
B.
C.
PLACE
OF
SERVICE
EMG
.
F
signature on file
20. OUTSIDE LAB?
$CHARGES
YES
NO
22. MEDICADE RESUBMISSION
CODE
ORIGINAL REF. #
.
23. PRIOR AUTHORIZATION #
.
D. PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
E.
DIAGNOSIS
POINTER
F.
G.
H.
I.
J.
$ CHARGES
DAYS
OR
UNITS
EPSDT
Family
Plan
ID.
QUAL.
PROVIDER ID. #
(1, 2, 3, or 4)
NPI
NPI
NPI
NPI
26. PATIENT’S ACCOUNT #
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
$
$
$
(For govt. claims, see back)
YES
NO
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
32. SERVICE FACILITY LOCATION INFORMATION
33. BILLING PROVIDER INFO & PH #
SIGNED
a.
a.
DATE
.
18.
MEDICAID
(Medicaid #)
TRICARE
CHAMPUS
(Sponsor’s SSN)
CHAMPVA
(Member ID #)
2. PATIENT’S NAME (Last Name, First Name, MI)
GROUP
HEALTH PLAN
(SSN or ID)
FECA
BLK LUNG
(SSN)
3. PATIENT’S BIRTH DATE
MM
DD
YY
Doe, Katherine
01
01
5. PATIENT’S ADDRESS ( #, Street)
1111 Noname Court
CITY
STATE
Nowhere
NY
ZIP CODE
TELEPHONE (Include Area Code)
22222
(
OTHER
1a. INSURED’S I.D. #
(ID)
999000666
SEX
M
4. INSURED’S NAME (Last Name, First Name, MI)
F
Doe, James
1950
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED’S ADDRESS ( #, Street)
Self
Spouse
8. PATIENT STATUS
CITY
Single
Child
1111 Noname Court
Other
Married
Nowhere
Other
ZIP CODE
Employed
)
9. OTHER INSURED’S NAME (Last Name, First Name, MI)
Full-Time
Student
Part-Time
Student
(
MM
DD
YY
M
MM
PLACE (State)
YES
F
a. INSURED’S DATE OF BIRTH
NO
b. AUTO ACCIDENT?
SEX
c. OTHER ACCIDENT?
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. LOCAL USE
DD
d. HEALTH BENEFIT PLAN?
14. DATE OF CURRENT:
MM
DD
YY
ILLNESS (First symptom) OR
INJURY (Accident) OR
PREGNANCY (LMP)
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
V70.0
.
24. A.
.
DATE(S) OF SERVICE
From
To
DD
YY
MM
4. |
DD
YY
UN
IV
MM
.
3. |
25. FEDERAL TAX I.D. #
.
SSN EIN
B.
C.
PLACE
OF
SERVICE
EMG
.
F
signature on file
20. OUTSIDE LAB?
$CHARGES
YES
NO
22. MEDICADE RESUBMISSION
CODE
ORIGINAL REF. #
.
23. PRIOR AUTHORIZATION #
.
D. PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
E.
DIAGNOSIS
POINTER
F.
G.
H.
I.
J.
$ CHARGES
DAYS
OR
UNITS
EPSDT
Family
Plan
ID.
QUAL.
PROVIDER ID. #
(1, 2, 3, or 4)
NPI
NPI
NPI
NPI
26. PATIENT’S ACCOUNT #
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
$
$
$
(For govt. claims, see back)
YES
NO
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
32. SERVICE FACILITY LOCATION INFORMATION
33. BILLING PROVIDER INFO & PH #
SIGNED
a.
a.
DATE
.
18.