CMS-1500 (08-05) Health Insurance Claim Form

Request for Medicare Payment

CMS-1500 (08-05)

Request for Medicare Payment

OMB: 3220-0131

Document [pdf]
Download: pdf | pdf
I

SIGNED

DATE

a.

NUCC lnstrudion Manual available at: www.nucc.org

b.

PLEASE FRNT OR TYPE

a.

I"
APPROVED OMB-OQ28-OQ99FORM CMS-1500 [OR-05)

RECWUSE Tt,::S it>%:> !S USED BY VARIOUS GWERWWEWT A N D PRIVATE HEALTH PROGRAPGIS.SEE SEPARATE INSTRUCTIONS ISSlJED BY
W$>PgC::',E!.,:I i'i.:.>GRW$.l$,

BLACK LUNG AND FECA CLAlUS

:

., ....'>*.<."'?..

,
:.i

',

8

..".,i
r':"'".:.

........
;,.:,

:,t+ tro,;) :::*:{?$>] >fig1 ::<:A,!:;
bph3!$1 ::A>,i*

];,>$c..


File Typeapplication/pdf
File Modified2009-09-23
File Created2009-09-23

© 2024 OMB.report | Privacy Policy