Form CMS-1500(02-12) Claim Form

P
M
A
S
PLEASE PRINT OR TYPE

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APPROVED OMB-0938-1197 FORM 1500 (02-12)

P
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PLEASE PRINT OR TYPE

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APPROVED OMB-0938-1197 FORM 1500 (02-12)

CARRIER

HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
PICA

PICA
TRICARE

CHAMPVA

(ID#/DoD#)

(Member ID#)

GROUP
HEALTH PLAN
(ID#)

FECA
BLK LUNG
(ID#)

3. PATIENT’S BIRTH DATE
DD
YY
MM

2. PATIENT’S NAME (Last Name, First Name, Middle Initial)

(ID#)

5. PATIENT’S ADDRESS (No., Street)

F

6. PATIENT RELATIONSHIP TO INSURED

CITY

STATE

8. RESERVED FOR NUCC USE

STATE

CITY

TELEPHONE (Include Area Code)

(

7. INSURED’S ADDRESS (No., Street)

Other

Child

Spouse

Self

ZIP CODE

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

SEX
M

ZIP CODE

TELEPHONE (Include Area Code)

(

)

)

9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

10. IS PATIENT’S CONDITION RELATED TO:

11. INSURED’S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED’S POLICY OR GROUP NUMBER

a. EMPLOYMENT? (Current or Previous)

a. INSURED’S DATE OF BIRTH
MM
DD
YY

b. RESERVED FOR NUCC USE

b. AUTO ACCIDENT?

PLACE (State)

c. OTHER ACCIDENT?

c. INSURANCE PLAN NAME OR PROGRAM NAME
NO

YES
d. INSURANCE PLAN NAME OR PROGRAM NAME

10d. CLAIM CODES (Designated by NUCC)

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES

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.

15. OTHER DATE

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

17a.

QUAL.

MM

DD

YY

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
YY
MM
DD
MM
DD
YY
TO
FROM
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
YY
MM
DD
MM
DD
YY
TO
FROM

19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E)
B.

C.

D.

E.

F.

G.

H.

MM

YY

B.
C.
PLACE OF
SERVICE EMG

NO

22. RESUBMISSION
CODE

ICD Ind.

A.

J.

$ CHARGES

20. OUTSIDE LAB?
YES

DATE(S) OF SERVICE
From
To
DD
YY
MM
DD

If yes, complete items 9, 9a and 9d.

SIGNED

17b. NPI

I.
24. A.

NO

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize
payment of medical benefits to the undersigned physician or supplier for
services described below.

DATE

SIGNED
14. DATE OF CURRENT ILLNESS, INJURY or PREGNANCY (LMP)
MM
DD
YY
QUAL.

F

b. OTHER CLAIM ID (Designated by NUCC)

NO

YES
c. RESERVED FOR NUCC USE

SEX
M

NO

YES

ORIGINAL REF. NO.

23. PRIOR AUTHORIZATION NUMBER

K.
L.
D. PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER

E.
DIAGNOSIS
POINTER

F.

H.

G.

$ CHARGES

I.

J.
RENDERING
PROVIDER ID. #

EPSDT
ID.
Family
Plan QUAL.

DAYS
OR
UNITS

1

NPI

2

NPI

3

NPI

4

NPI

5

NPI

6

NPI

25. FEDERAL TAX I.D. NUMBER

SSN EIN

26. PATIENT’S ACCOUNT NO.

27. ACCEPT ASSIGNMENT?
(For

govt. claims, see back)

YES
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)

SIGNED

DATE

NO

32. SERVICE FACILITY LOCATION INFORMATION

a.

NUCC Instruction Manual available at: www.nucc.org

NPI

PATIENT AND INSURED INFORMATION

MEDICAID

(Medicaid#)

(For Program in Item 1)

b.

PLEASE PRINT OR TYPE

28. TOTAL CHARGE
$

$

33. BILLING PROVIDER INFO & PH #

a.

30. Rsvd for NUCC Use

29. AMOUNT PAID

NPI

(

)

b.

APPROVED OMB-0938-1197 FORM 1500 (02-12)

PHYSICIAN OR SUPPLIER INFORMATION

MEDICARE

(Medicare#)

1.

OTHER 1a. INSURED’S I.D. NUMBER