HCFA Box Patient's DOB, Patient's Relationship to Patient Employer's Name Insurance Plan Name or Is Patient's Condition Is Patient's Condition Related to Is Patient's Condition Related to Other Insured's Employer Name or School
Title Carrier Block Type of Coverage Insured's ID # Patient's Name Sex Insured's Name Patient's Address Insured Insured's Address Status Other Insured's Name Other Insured's policy/group no. Other Insured's DOB, Sex or School Name Program Name Related to Employment? Auto Accident? Accident? Reserved for Local Use Insured's Policy, Group or FECA No. Insured's Date of Birth, Sex Name Insurance Plan Program or Name
HCFA Box No Box No n/a Box 1 Box 1a Box 2 Box 3 Box 4 Box 5 Box 6 Box 7 Box 8 Box 9 Box 9a Box 9b Box 9c Box 9d Box 10a Box 10b Box 10c Box 10d Box 11 Box 11a Box 11b Box 11c
Patient's Accept
Patient's or Authorized Person's Date of Current Illness, Injury, If Patient Has Had Same Dates Patient Unable to Work Name of Referring Hospitalization Dates Related Outside Lab Diagnosis or Nature of Medicaid Resubmission and/or Prior Authorization Procedures, Services or EPSDT/Family Rendering Federal Account Assignment Total Amount Balance Signature of Physician or Supplier Service Facility Other ID Billing Provider Other
Is there another health benefit Plan? Signature Insured's or Authorized Person's Signature Pregnancy or Similar Illness in Current Occupation Provider or Other Source Other ID# NPI # to Current Services Reserved for Local Use Charges Illness or Injury Original Reference Number Number Dates of Service Place of Service EMG Supplies Diagnosis Pointer $ Charges Days or Units Plan ID Qualifier Provider ID # Tax ID # No. ? Charge Paid Due Including Degrees and Credentials Location Information NPI # # Info & Ph NPI # ID#
Box 11d Box 12 Box 13 Box 15 Box 15 Box 16 Box 17 Box 17a Box 17b Box 18 Box 19 Box 20 Box 21 Box 22 Box 23 Box 24A Box 24B Box 24C Box 24D Box 24E Box 24F Box 24G Box 24H Box 24I Box 24J Box 25 Box 26 Box 27 Box 28 Box 29 Box 30 Box 31 Box 32 Box 32a Box 32b Box 33 Box 33a Box 33b