HCFA INSURANCE FORMS

26-27.qxd 5/15/05 10:42 PM Page 27 PLEASE DO NO T STAPLE IN THIS AREA PICA 1. MEDIC ARE MEDIC AID (Medica re #) 2. PATIEN (Medica id) T’S NAM E (Last Name, First Laser HCFA INSURANCE FORMS Continuous PLEASE DO NO T STAPLE IN THIS AREA APPROV ED OM B-0938 -0008 PICA 1. MEDIC ARE MEDIC AID (Medica re #) CHAMP US 2. PATIEN (Medica id) T’S NAM E (Last (Spons Name, or’s SSN First Nam ) e, Middle Initial) 5. PATIEN T’S ADD RESS (No., Stre et) CITY APPROV ED OM B-0938 -0008 CHAM PUS 1 2 3 SUPPLIE R INFOR MATIO N 4 4 5 5 2 PLY 6 25. FED ERAL TAX I.D. NU MBER 6 25. FED ERAL TAX I.D. NUM BER SSN 31. SIG EIN NAT INCLUD URE OF PHY (I certify ING DEGREESICIAN OR apply to that the stat S OR CRE SUPPLIER DENTIA eme this bill and are nts on the reve LS made a rse par t ther eof.) 790-01 30 (12/90 ) (OCR) PHYSICI AN OR SIGNED (APPRO VED BY DATE AMA CO UNCIL ON ME DICAL SERVIC E 8/88 ) 28. TOT AL CH ARGE $ 29. AM OUNT PAID 33. PHY SICIAN 30. BAL $ ’S SUP ANCE & PHO PLIER’ DUE NE # S BILLIN $ G NAM E, ADD RESS, ZIP CO DE SIGNED (APPRO VED BY PLEASE PRINT OR DATE AMA CO UNCIL ON ME DICAL SERVIC E 8/88) 28. TOT AL CHA RGE $ 29. AM OUNT PAID 33. PHY SICIAN 30. BAL $ ’S SUP ANCE & PHO PLIER’ DUE NE # S BILLIN $ G NAM E, ADD RESS, ZIP CO DE PIN# TYPE GRP# FROM HCFA150 FORM OWCP- 0 (12-90) 1500 FORM RRB-1 500 PLEASE PRINT OR PIN# TYPE GRP# FROM HCFA-1 500 (12FORM OWCP90) 1500 FORM RRB-150 0 HC10SS FEDERA L TAX I.D. NUM BER v .) D TE O HC912 HC10RG Submission Envelopes The window placement is specifically designed to have the insurance carrier’s name and address show through the window (provided your computer prints out the insurance carrier’s name and address in the upper right-hand corner.) Available in regular moist & seal or convenient self-seal, both have security interior tint. Right hand window. HC10RG Regular x Blank (500/box) HC10SS Self-Seal (91/2" x 41/8") Blank (500/box) (91/2" 41/8") HCFA Approved Medical Insurance Forms All forms are government approved HCFA-1500 12/90 revision to serve federal programs and private insurers as a universal claim form. Multiple part forms are carbonless. HCFA-1500 – Health Claim Forms # of Item # Description Parts 790-0128HC Laser (W) 1 790-0129HC Laser (W) 1 790-0115HC Cont (W) 1 790-0116HC Cont (W) 1 790-0119HC Cont (W,C) 2 790-0117HC Cont (W,W) 2 790-0120HC Cont (W,C) 2 790-0118HC Cont (W,W) 2 Bar Code Y N Y N Y Y N N Carton Qty 2500 2500 2500 2500 1000 1000 1000 1000 7891HL READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. SIGNED DATE 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I aut payment of medical benefits to the undersigned physician or supp services described below. Jumbo insurance envelope is designed to accommodate up to 50 insurance claims to the same carrier. HC912 Side-Seal HCFA Envelopes (9" x 13") (100/pkg.) Insurance Signature Release Labels Save time by having patient sign several of these labels on their first visit. They can be used for subsequent claims as needed. Compatible with HCFA-1500 forms. 7891HL – 5/8" H x 7" W Self Adhesive Label SIGNED Insurance Signature Release Labels MAP comparable forms PHYSICI AN OR 26. PAT IENT’S ACCOU NT NO . 27. ACC 32. NAM EPT E AND (For gov ASSIGNME ADDRES RENDER YES t. claims, see NT? ED (If othe S OF FACILIT back) NO Y WH r than hom e or offic ERE SERVIC ES WE e) RE 790-01 15 (12 /90) (OC R) SSN 31. SIG EIN NAT INCLUD URE OF PHY (I certify ING DEGREESICIAN OR SUP apply to that the stat S OR CREDE PLIER eme this bill and are nts on the NTIALS reverse made a par t ther eof.) 26. PAT IENT’S ACCOU NT NO. 27. ACC 32. NAM EPT E AND (For gov ASSIGNME ADDRES RENDER YES t. claims, see NT? ED (If othe S OF FACILIT back) NO Y WH r than hom e or offic ERE SERVIC ES WE e) RE SUPPLIE R INFOR MATIO N GROU P HEALTH #) PLA (SSn or N ID) 3.PATIE NT’S BIR N) ED’S I.D. TH DAT MM NUMB (ID) E DD ER YY PICA (FOR PRO SEX 6.PATIE 4. INSUR GRAM NT’S REL M ED’S NAM ITEM 1) ATION F E (Last SHIP TO ZIP CO Name, Self INSUR DE First Nam ED STATE Spouse e, Middle 8.PATIE 7. INSUR Initial) Child NT STA TELEPH ED’S ADD TUS Other ONE (Inc RESS 9. OTH lude Are ( No., Stre ER INS Single a Code) et) URED’ S NAM Married CITY E (Last Name, Other First Nam Employ ed a. OTH e, Middle ER INS Full-Tim Initial) URED’ e S POLIC Par t-Ti Studen 10. IS PAT ZIP CO me Y OR GR t DE IENT’S OUP NU Studen STATE COND t MBER ITIONS b. OTH RELATE ER INS TELEPH D TO: URED’ MM ONE (INC S DATE DD a.EMP 11. INS LUDE OF BIR LOYME YY AREA URED’ TH NT? (CU CODE) S POLIC RRENT Y GROU c. EMPLO OR PRE P OR FEC YER’S VIOUS) NAME SEX A NUMB YES M OR SCH b. AUT ER a. INSUR O ACC OOL NAM NO ED’S DAT IDENT? F E E OF BIR d. INSUR MM TH PLACE DD ANCE PLAN (State) YY YES NAME c. OTH b. EMPLO OR PRO ER ACC NO YER’S GRAM IDENT? NAME SEX NAME OR SCH M OOL NAM 12. PAT F E YES IENT’S READ 10d. RES c. INSUR BACK to proces OR AUTHO ERVED NO ANCE OF FOR LOC PLAN below. s this claim. RIZED PERSO FORM BEF NAME AL USE I also req OR N’S SIG OR PRO uest pay NATUR E COMPLET GRAM ING & ment of E NAME SIGNED SIGNIN govern I authorize the d. IS THE ______ G THIS ment ben release RE ANO ______ FORM. efits eith 14. DAT of THER ______ E OF CU er to mys any medical HEALTH ______ or othe RR elf or to ______ MM BENEFI YES r informa ______ the par DD YY ENT: T PLAN? tion nec ty who ______ NO ILLNESS 13. INS ess accepts ______ URED’ If yes, ______ assignm ary INJURY (First symptom 17. NAM return paymen S OR AUTHO ent (Accide E OF REF to and ) OR t DATE ___ PREGN complet nt) OR services of medical ben RIZED PER ERRING ______ 15. IF PAT ANCY e item SO efits to describ PHYSIC ______ (LMP) 9 a-d. IEN the und N’S SIGNATUR ed belo IAN OR ______ GIVE FIR T HAS HAD w. ersigne ______ OTHER SOME d physici E I authorize ST DAT ___ 19. RES SOUR OR SIM an or sup E MM CE ERVED SIGNED plier for FOR LOC DD YY ILAR ILLNESS ______ 17a. ID ______ AL USE NUMB 16. DAT ______ ER OF ES PAT ______ REFERR IENT UN ______ 21. DIA ING PHY ABLE TO GNOS MM ______ SICIAN IS OR ______ FROM WORK DD NATUR ______ IN CURR YY E OF ILLN ____ 18. HO ENT OC SPITAL ESS OR CUPAT 1. MM IZATIO INJURY ION N DATES DD . (RELAT TO MM YY RELATE E ITEMS DD FROM D TO CU 1,2,3 OR YY RRENT 4 TO ITE 20. OU 2. SERVIC TSIDE M 24E MM ES LAB? BY LIN 24. DD E) TO A YY 3. YES $ CHARG DATE(S NO ES 22. ME ) OF SER From DICAID MM VICE RESUBM B CODE DD ISSION C 4. YY To Place MM Type DD PROCED 23. PRI ORIGIN D YY Serof of OR AUT UR AL REF vice Ser HORIZ . NO. (Explai ES, SERVICES, vice ATION CPT/HC n Unusua OR NUMB l Circums SUPPLIES PCS ER E MODIF tances) IER DIAGN F OS CODE IS G H $ CHARG DAYS I ES EPSDT J OR K UNITS Family EM G CO Plan B RESERV LOCALED FOR USE 5. PATIEN T’S ADD RESS (No., (VA File Street) CITY CARRIER ( ) ( ) 1 2 3 GROU P HEALTH FECA #) PLA (SSn or N BLK LUN OTHER ID) G 3.PATIE 1a. INS NT’S BIR (SSN) URED’S TH DAT I.D. NUM MM (ID) E BER DD YY PICA (FOR PRO SEX 6.PATIE 4. INSURE GRAM NT’S REL M ITEM 1) D’S NAM ATIONSH E (Last F IP TO INS Name, ZIP CO Self First Nam DE URED STATE Spouse e, Middle 8.PATIE 7. INSURE Initial) Child NT STA TELEPH D’S ADD TUS Other ONE (Inc RESS ( No., Stre 9. OTH lude Are ER INS Single et) a Code) URED’S Married NAME CITY (Last Nam Other e, First Employ Name, ed a. OTH Middle Full-Tim ER INS Initial) e URED’S Par t-Tim Studen POLICY 10. IS PAT ZIP CO t e OR GR DE IENT’S STATE Studen OUP NUM CONDI t TIONS BER b. OTH RELATE TELEPH ER INS D TO: ONE (INC URED’S MM DATE OF a.EMP LUDE DD 11. INS LOYME AREA URED’S YY BIRTH CODE) NT? (CU POLICY RRENT GROU c. EMPLO OR PRE P OR FEC YER’S VIOUS) A NUM SEX NAME YES BER M b. AUTO OR SCH a. INSURE ACCIDE OOL NAM NO D’S DAT NT? F E E OF BIR MM d. INSURA TH DD PLACE NCE PLA YY (State) YES N NAM c. OTH b. EMPLO E OR PRO ER ACC NO YER’S GRAM IDENT? SEX NAME NAME OR SCH M OOL NAM F 12. PAT E YES IENT’S 10d. RES READ c. INSURA OR AUT BACK to proc ERVED NO NCE PLA HORIZ ess this FOR LOC ED PER OF FORM BEF N NAM claim. I below. AL USE SON’S E OR PRO also requ SIGNAT ORE COMPLET GRAM est pay URE ING & NAME ment of SIGNED SIGNIN d. IS THE govern I authorize the ______ G THIS ment ben release RE ANO ______ FOR efits eith of THER 14. DAT ______ HEALTH er to mys any medical M. E OF CUR ______ or othe BENEFI elf or to ______ YES REN MM r informa T PLAN? the par ______ DD YY T: tion nec ty who NO ______ 13. INS ILLNESS ess accepts ______ URED’S If yes, assignm ary ______ OR AUT return to INJURY (First symptom 17. NAM paymen ent HO (Accide and com ) OR E OF REF t DATE ___ PREGN nt) OR services of medical ben RIZED PERSON plete item ERRING ______ 15. IF PAT ANCY efits to describ 9 a-d. ______ PHYSIC (LMP) IEN the und ’S SIGNATURE ed belo ______ IAN OR ersigne w. GIVE FIR T HAS HAD ______ OTHER d physicia I authorize SOM ST DAT ___ SOURCE 19. RES n or sup E MM E OR SIMILA SIGNED ERVED plier for R ILLN DD YY ______ FOR LOC 17a. ID ESS ______ NUMBER AL USE 16. DAT ______ ES PAT OF REF ______ IENT UNA ERRING ______ 21. DIA ______ BLE TO MM PHYSIC GNOSI ______ WORK FROM DD IAN S OR NAT ______ IN CUR YY URE OF ____ RENT 18. HO ILLNESS OCCUP SPITAL MM ATION IZATION OR INJ 1. DD URY. (RE DATES TO MM YY LATE ITE RELATE DD FROM D TO CUR MS 1,2, YY 3 OR 4 RENT 20. OU TO ITE SERVIC 2. TSIDE M 24E MM ES LAB? BY LIN DD 24. E) TO YY A 3. YES $ CHA RGES DATE(S NO 22. ME ) OF SER DICAID From RESUBM MM VICE CODE B DD ISSION C 4. YY To Place MM Type DD PROCED of 23. PRI ORIGIN D YY Serv of OR AUT AL REF URES, ice Serv HORIZ . NO. SERVIC (Ex ATION ice CPT plain Unu ES, NUMBER sual Circ OR SUPPLI /HCPCS E umstanc ES es) MODIF IER DIAGN F OSI CODE S G H $ CHA DAYS RGES I EPSDT J OR K UNITS Family EM G CO Plan B RESERV LOCALED FOR USE (VA File ( ) PATIENT AND INS URED INFOR MATIO N ( ) 1pt. PATIENT AND INS URED INFOR MATIO N CARR IER (Spons or’s SSN ) Name, Middle Initial) CHAM PVA HEALTH INSURA FECA NCE CL BLK LUN OTHER AIM FO G 1a. INS RM (SS UR CHAMP VA HEALTH INSURA NCE CL AIM FO RM 27