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CARRIER
PICA

HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA
GROUP

p (Medicare #) p (Medicaid #) p(Sponsor's SSN)
5. PATIENT'S ADDRESS (No., Street)

1.

MEDICARE

MEDICAID

TRICARE CHAMPUS

CHAMPVA

(Medicaid #)

HEALTH PLAN (SSN or ID)
MM DD YY

p (SSN)
M

BLK LUNG

FECA

p (ID)
F

OTHER 1a.INSURED'S I.D. NUMBER

(FOR PROGRAM IN ITEM 1)

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

3. PATIENT'S BIRTH DATE

p

SEX

p p p p

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

6. PATIENT RELATIONSHIP TO INSURED
Self

p
Single

Spouse

p Child p
Married

7. INSURED'S ADDRESS (No., Street)

Other

p p

p p p p NO p

Other

ZIPCODE

TELEPHONE (Include Area Code)

ZIP CODE
Employed Full-Time Student Part-Time Student

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 OFBIRTH
MM DD YY

p YES
b. OTHER INSURED'S DATE OF BIRTH
MM DD YY

NO

M

p

SEX F

p

M

p

SEX F

b. AUTO ACCIDENT?

p

p YES p YES

PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME

c. EMPLOYER'S NAME OR SCHOOL NAME

c. OTHER ACCIDENT?

c. INSURANCE PLAN NAME OR PROGRAM NAME NO d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

d. INSURANCE PLAN NAME OR PROGRAM NAME10d. RESERVED FOR LOCAL USE

pYES

p NO

If yes, return to and complete item 9 a-d.

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

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
YY

SIGNED

14. DATE OF CURRENT:
MM DD

ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY(LMP)

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YYMM DD MM DD YY GIVE FIRST DATE FROM TO 17a. 17 b. NPI 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD FROM TO 20. OUTSIDE LAB? $ CHARGES

YY

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

YY

19. RESERVED FOR LOCAL USE

pYES
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 1. 2. 24. A. MM DATE(S) OF SERVICE From DD YY MMTo DD YY B. C. Place of Service EMG D. 3. 4.

p NO
ORIGINAL REF. NO.

22. MEDICAID RESUBMISSION CODE

23. PRIOR AUTHORIZATION NUMBER

CPT/HCPCS

MODIFIER

POINTER

$ CHARGES

RENDERING PROVIDER ID. #

1 2 3 4 5 6
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?

NPI

NPI

NPI

NPI

NPI

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

p YES p NO
32. SERVICE FACILITY LOCATION INFORMATION

(For govt. claims, see back)

28. TOTAL CHARGE $

NPI 29. AMOUNT PAID $

30. BALANCE DUE $

33. BILLING PROVIDER INFO & PH #

(

)

SIGNED

DATE

a.

b.

a.

b. OMB No. 1240-0044 Expires:11/30/2012

NUCC Instruction Manual available at: www.nucc.org

PHYSICIAN OR SUPPLIER INFORMATION

PROCEDURES, SERVICES, OR SUPPLIES E. (Explain Unusual Circumstances) DIAGNOSIS

F.

G. H. I. DAYS EPSDT OR Family ID UNITS Plan QUAL..

J.

PATIENT AND INSURED INFORMATION

CITY

STATE

8. PATIENT STATUS

CITY

STATE

Instructions for Completing OWCP-1500 Health Insurance...