Appendix C. 1a Feasibility Study
Appendix C
1. MEDICARE (Medicare #) MEDICAID (Medicaid #) TRICARE CHAMPUS (Sponsor’s SSN) CHAMPVA (Member ID #) GROUP HEALTH PLAN (SSN or ID) FECA BLK LUNG (SSN) OTHER (ID) SEX M 1a. INSURED’S I.D. # (For Program in Item 1)
999000666
4. INSURED’S NAME (Last Name, First Name, MI) F
2. PATIENT’S NAME (Last Name, First Name, MI)
Doe, Katherine
5. PATIENT’S ADDRESS ( #, Street)
3. PATIENT’S BIRTH DATE MM DD YY
01
01
1950
Child Other
Doe, James
7. INSURED’S ADDRESS ( #, Street)
6. PATIENT RELATIONSHIP TO INSURED Self Spouse 8. PATIENT STATUS Single Employed
CITY
STATE
PH O EN
CITY
1111 Noname Court
Nowhere
ZIP CODE
1111 Noname Court
NY
TELEPHONE (Include Area Code)
Married Full-Time Student
Other …show more content…
Nowhere
ZIP CODE
TELEPHONE (Include Area Code)
22222
(
) N/A
Part-Time Student
22222
(
9.
OTHER INSURED’S NAME (Last Name, First Name, MI)
10. IS PATIENT’S CONDITION RELATED TO:
11. INSURED’S POLICY GROUP OR FECA #
123456
MM
a. OTHER INSURED’S POLICY OR GROUP #
a. EMPLOYMENT? (Current of Previous) YES NO
a. INSURED’S DATE OF BIRTH DD YY
M
b. INSURED’S DATE OF BIRTH MM DD YY M c. EMPLOYER’S NAME OR SCHOOL NAME
SEX F
b. AUTO ACCIDENT? YES c. OTHER ACCIDENT? YES 10d. LOCAL USE NO NO
PLACE (State)
b. EMPLOYER’S NAME OR SCHOOL NAME
U.S Army Tricare
YES
c. INSURANCE PLAN NAME OR PROGRAM NAME
None
d. INSURANCE PLAN NAME OR PROGRAM NAME
d. HEALTH BENEFIT PLAN? NO
If yes, return to and complete item 9 a-d.
14. DATE OF CURRENT: MM DD YY
ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP)
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM DD YY
O
SIGNED
SIGNATURE ON FILE
DATE
F
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENTS OR AUTHORIZED PERSON’S SIGNATURE
13. INSUREDS OR AUTHORIZED PERSON’S SIGNATURE
.
SIGNED
FROM
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD YY TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
17a.
19. RESERVED FOR LOCAL USE
TY
17b.
NPI
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO 20. OUTSIDE LAB? $CHARGES
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. | 2. | 24. A. MM
N/A .
. .
3. |
N/A .
YES NO 22. MEDICADE RESUBMISSION CODE ORIGINAL REF. # 23. PRIOR AUTHORIZATION #
.
SI
N/A .
4. |
N/A .
. E. DIAGNOSIS POINTER
(1, 2, 3, or 4)
DATE(S) OF SERVICE From To DD YY MM
B.
C.
DD
YY
PLACE OF SERVICE
EMG
D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER
F. $ CHARGES
G.
DAYS OR UNITS
H.
EPSDT Family Plan
I.
ID. QUAL.
ER
NPI
NPI
NPI
UN IV
NPI 26. PATIENT’S ACCOUNT # 27. ACCEPT ASSIGNMENT?
(For govt. claims, see back)
25. FEDERAL TAX I.D. #
SSN EIN
28. TOTAL CHARGE $
29. AMOUNT PAID $
YES 32. SERVICE FACILITY LOCATION INFORMATION
NO
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS
33. BILLING PROVIDER INFO & PH #
(
SIGNED
DATE
a.
b.
a.
b.
IX
STATE
NY
) N/A
SEX
F
.
J. PROVIDER ID. #
30. BALANCE DUE $
)
1. MEDICARE (Medicare #) MEDICAID (Medicaid #) TRICARE CHAMPUS (Sponsor’s SSN) CHAMPVA (Member ID #) GROUP HEALTH PLAN (SSN or ID) FECA BLK LUNG (SSN) OTHER (ID) SEX M 1a. INSURED’S I.D. # (For Program in Item 1)
999000666
4. INSURED’S NAME (Last Name, First Name, MI) F
2. PATIENT’S NAME (Last Name, First Name, MI)
Doe, Katherine
5. PATIENT’S ADDRESS ( #, Street)
3. PATIENT’S BIRTH DATE MM DD YY
01
01
1950
Child Other
Doe, James
7. INSURED’S ADDRESS ( #, Street)
6. PATIENT RELATIONSHIP TO INSURED Self Spouse 8. PATIENT STATUS Single Employed
CITY
STATE
PH O EN
CITY
1111 Noname Court
Nowhere
ZIP CODE
1111 Noname Court
NY
TELEPHONE (Include Area Code)
Married Full-Time Student
Other …show more content…
Nowhere
ZIP CODE
TELEPHONE (Include Area Code)
22222
(
) N/A
Part-Time Student
22222
(
9.
OTHER INSURED’S NAME (Last Name, First Name, MI)
10. IS PATIENT’S CONDITION RELATED TO:
11. INSURED’S POLICY GROUP OR FECA #
123456
MM
a. OTHER INSURED’S POLICY OR GROUP #
a. EMPLOYMENT? (Current of Previous) YES NO
a. INSURED’S DATE OF BIRTH DD YY
M
b. INSURED’S DATE OF BIRTH MM DD YY M c. EMPLOYER’S NAME OR SCHOOL NAME
SEX F
b. AUTO ACCIDENT? YES c. OTHER ACCIDENT? YES 10d. LOCAL USE NO NO
PLACE (State)
b. EMPLOYER’S NAME OR SCHOOL NAME
U.S Army Tricare
YES
c. INSURANCE PLAN NAME OR PROGRAM NAME
None
d. INSURANCE PLAN NAME OR PROGRAM NAME
d. HEALTH BENEFIT PLAN? NO
If yes, return to and complete item 9 a-d.
14. DATE OF CURRENT: MM DD YY
ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP)
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM DD YY
O
SIGNED
SIGNATURE ON FILE
DATE
F
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENTS OR AUTHORIZED PERSON’S SIGNATURE
13. INSUREDS OR AUTHORIZED PERSON’S SIGNATURE
.
SIGNED
FROM
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD YY TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
17a.
19. RESERVED FOR LOCAL USE
TY
17b.
NPI
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO 20. OUTSIDE LAB? $CHARGES
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. | 2. | 24. A. MM
N/A .
. .
3. |
N/A .
YES NO 22. MEDICADE RESUBMISSION CODE ORIGINAL REF. # 23. PRIOR AUTHORIZATION #
.
SI
N/A .
4. |
N/A .
. E. DIAGNOSIS POINTER
(1, 2, 3, or 4)
DATE(S) OF SERVICE From To DD YY MM
B.
C.
DD
YY
PLACE OF SERVICE
EMG
D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER
F. $ CHARGES
G.
DAYS OR UNITS
H.
EPSDT Family Plan
I.
ID. QUAL.
ER
NPI
NPI
NPI
UN IV
NPI 26. PATIENT’S ACCOUNT # 27. ACCEPT ASSIGNMENT?
(For govt. claims, see back)
25. FEDERAL TAX I.D. #
SSN EIN
28. TOTAL CHARGE $
29. AMOUNT PAID $
YES 32. SERVICE FACILITY LOCATION INFORMATION
NO
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS
33. BILLING PROVIDER INFO & PH #
(
SIGNED
DATE
a.
b.
a.
b.
IX
STATE
NY
) N/A
SEX
F
.
J. PROVIDER ID. #
30. BALANCE DUE $
)