HOSPITAL NAME ____________________________ A STANDARD HEALTH INSURANCE CLAIM FORM E

							                                                                                                                   HOSPITAL NAME: ____________________________

                     A STANDARD HEALTH INSURANCE CLAIM FORM (E.G. UB 92) MUST BE INCLUDED WITH EACH CLAIM
                               NON-COUNTY HOSPITAL SUPPLEMENTAL CLAIM DATA FOR RECEIPT OF CHIP FUNDS
                                                                                   ALL PATIENTS
 Patient Name                                             Is this          Type of Service         Other Potential        Ethnicity1     Family                 Family    Family
                                                          a CHDP           1 = Inpatient           3rd Party Payer?                      Size                   Monthly   Income
                                                          follow-up?       2 = Outpatient          (Name)                                                       Income    Source2
                                                          (Y/N)            3 = ER
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 1=      White, Black, Hispanic, Native American/Eskimo/Aleut, Asian/Pacific Islander OR Other
 2=      Professional/Technical Employment, Labor/Production Employment, Agricultural Employment, Service/Sales Employment, Retirement Income,
         Disability/Workers Compensation, General or Public Assistance, Other Income Source (e.g. VA benefits, interest, dividends, rent, child support, alimony,
         unemployment benefits, etc.), OR None

                                                                                                    Submitted by (name/title): ___________________________________
                                        Please return completed form to:
                                                 Kern County EMS Department                                             Signature: ___________________________________
                                                 1400 H Street, Bakersfield, CA 93301
                                                 Phone: (661) 868-5201
(chiphospclaim.wpd - 03/07)                                                                                                    Date: ___________________________________
                                                 Fax: (661) 322-8453
                                                 E-mail: bertholfv@co.kern.ca.us