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					                                                                                                                                                                                            Name Here
                                                                                                                                                                                            Address
          1500
                                                                                                                                                                                            City, State
    HEALTH INSURANCE CLAIM FORM                                                                                                                                                             Zip
    x    x      x      x    x                                                                     x               x
    APPROVED BY THE UNIFORM CLAIM COMMITTEE 08/05
               PICA
                                                                                                          x                 x                                                                                                                                  PICA

    1. MEDICARE                  MEDICAID                TRICARE                             x
                                                                                        CHAMPVA           x      GROUPx                      FECA                OTHER   1a. INSURED'S I.D. NUMBER                                          (For Program in Item 1)
                                                         CHAMPUS                                                 HEALTH                      BLK
     x    Medicare #            Medicaid #               Sponsor's SSN                   x
                                                                                        MemberID#     x                  x
                                                                                                                 SSN or ID                   SSN                  ID


    XXxx……………………………….XXXXXXXX
    2. PATIENTS NAME (Last Name, First Name, Middle Initial)                                         3. PATIENTS BIRTH DATE
                                                                                                          MM           DD             YY
                                                                                                                                                                         4. INSURED'S NAME (Last Name, First name, Middle Initial)
     Joseph L Blow                                                                                                                            M               F

    5. PATIENT'S ADDRESS (No., Street)                                                               6. PATIENT RELATIONSHIP TO INSURED                                  7. INSURED'S ADDRESS (No., Street)
     SAMPLE SHEET ONLY                                                                                    Self          Spouse             Child         Other

    CITY
    CITY                                                                                  STATE      8. PATIENT STATUS                                                   CITY                                                                                  STATE
     YOUR ICD-9-CM GUIDELINES MAY VARY                                                                         Single             Married                Other
    ZIP CODE                                   TELEPHONE (Include Area Code)                                                                                             ZIP CODE                                       TELEPHONE (Include Area Code)
                                                                                                                     Full-Time    Part Time
                                                (             )                                        Employed        Student   Student                                                                                         (              )
    XXxx………………….XXXXXXXXxxxxxxxxxXX
    9. OTHER INSURED'S NAME (Last Name, First Name, Middle In.)                                      10. IS PATIENT CONDITION RELATED TO;                                11. INSURER'S POLICY GROUP OR FECA NUMBER


    a . OTHER INSURED'S POLICY OR GROUP NUMBER                                                       a. EMPLOYMENT? (Current or Previous)                                a. INSURER'S DATE OF BIRTH
    AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA                                                                                                                                              MM       DD             YY                                X       SEX         X

                                                                                                                   YES                              NO                                                   M
                                                                                                                                                                         b. EMPLOYER'S NAME OR SCHOOL NAME                                                     F
    b. OTHER INSURER'S DATE OF BIRTH                                                                 b. AUTO ACCIDENT?
         MM         DD         YY                                     SEX                                                                            PLACE (State)       b. EMPLOYERS NAME OR SCHOOL NAME

                                                         M                   F                                     YES                              NO                   c. EMPLOYER'S NAME OR SCHOOL NAME
    c . EMPLOYER'S NAME OR SCHOOL NAME                                                               c. OTHER ACCIDENT?                                                  c. INSURANCE PLAN NAME OR PROGRAM NAME
                                                                                                                                YES                 NO

    d. INSURANCE PLAN NAME OR PROGRAM NAME                                                           10d. RESERVED FOR LOCAL USE                                         d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
                                                                                                                                                                                      YES               NO        If yes, return to and complete item 9 a-d.
                                     READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.                                                                            13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
    12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary                                                      payment of medical benefits to the undersigned physician or supplier for
          to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment                                        services described below.
               VVV…………………..
          below.                                                                        ,,,oooo///
         SIGNED                          SIGNATURE ON FILE                                                             DATE                                                    SIGNED                    SIGNATURE ON FILE
    14. DATE OF CURRENT:                                                                       15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS                             16. DATED PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
                                             ILLNESS (First Symptom) OR
         MM       DD           YY                                                                   GIVE FIRST DATE               MM         DD      YY                                MM        DD                YY                          MM         DD       YY
                                             INJURY (Accident) OR
                                             PREGNANCY (LMP)                                                                                                                  FROM                                                     TO
    17. NAME OF REFERRING PROVIDER OR OTHER SOURCE                                            17a.                                                                        18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
                                                                                                                                                                                       MM          DD             YY                            MM        DD        YY
                                                                                              17b. NPI                                                                        FROM                                                     TO
    19. RESERVED FOR LOCAL USE                                                                                                                                             20. OUTSIDE LAB?                                             $ CHARGES
     TR/R1/9.5                                                                                                                                                                       YES                NO
                                                                                                                                                                         22. MEDICAID RESUBMISSION CODE
    21. DIAGNOSIS OR NATURE OF ILLNESS (Relate Items 1,2,3 or 4 to item 24E by LINE)                                                                                                                                                   ORIGINAL REF. NO.

    1.        285 . 22                                                                         3.      174 . 9
                     Hi Beautiful,                                                                                                                                       23. PRIOR AUTHORIZATION NUMBER

    2.        V58 . 11                                                                         4.                  .
    24. A.       DATE(S) OF SERVICE                                  B.       C.       D. PROCEDURES, SERVICES, OR SUPPLIES                                  E.                       F.                   G.             H.           I.                   J.
                                                                                                                                                                                                                        EPSDT         ID.
               FROM                          TO                             Place of                  xplain Unusual Circumstances)                      DIAGNOSTIC                                      DAYS or                                       PROVIDER ID#
                                                                                                                                                                                                                        Family
     MM        DD        YY         MM       DD          YY       SERVICE   EMG           CPT/HCPCS                             MODIFIER                  POINTER                $ CHARGES               UNITS           Plan        QUAL               RENDERING


1
     01        28 2008 01                    28 2008                                       J0881                  EA                                          1, 2                                       100                         NPI


2
     01        28 2008 01                    28 2008                                       90772                                                              1, 2                                           1                       NPI


3
                                                                                                                                                                                      $0.00                                          NPI


4
                                                                                                                                                                                      $0.00                                          NPI


5
                                                                                                                                                                                      $0.00                                          NPI


6
                                                                                                                                                                                      $0.00                                          NPI
    25. FEDERAL TAX I.D. NUMBER                          SSN EIN                 26. PATIENT'S ACCOUNT NO.                        27.ACCEPT ASSIGNMENT?                  28. TOTAL CHARGE                          29. AMOUNT PAID                    30. BALANCE DUE

                                                                                                                    YES                                  NO               $                   0.00                 $                   0.00           $                 0.00
    31. SIGNATURE OF PHYSICIAN OR SUPPLIER                                       32. SERVICE FACILITY LOCATION INFORMATION                                               33. BILLING PROVIDER INFO & PH #
                                                                                                                                                                                                                                     (     )
         INCLUDING DEGREES OR CREDENTIALS
      (I certify that the statements on the reverse
      apply to this bill and are made a part thereof.)




    SIGNED                                            DATE                       a.                                    b.                                                a.                                       b.
    NUCC Instruction Manual available at: www.nucc.org                                                                                                                         APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)

				
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