last portion on CMS-1500 2-12 form

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(For Program in Item 1)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

a. INSURED’S DATE OF BIRTH

b. OTHER CLAIM ID (Designated by NUCC)

SEX

HEALTH INSURANCE CLAIM FORM

OTHER1. MEDICARE MEDICAID TRICARE CHAMPVA

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.

SIGNED DATE

MM DD YY QUAL. QUAL.

MM DD YY 15. OTHER DATE

19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)

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

From MM DD YY

To MM DD YY

2 3 4

5 6

25. FEDERAL TAX I.D. NUMBER SSN EIN 27. ACCEPT ASSIGNMENT? (For govt. claims, see back)

SIGNED DATE

SIGNED

MM DD YY

FROM TO

MM DD YY MM DD YY

CODE ORIGINAL REF. NO.

28. TOTAL CHARGE 29. AMOUNT PAID 30. Rsvd for NUCC Use

$ $ $

PICA PICA

CITY STATE

ZIP CODE

d. INSURANCE PLAN NAME OR PROGRAM NAME

YES NO

If yes,

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

20. OUTSIDE LAB?

22. RESUBMISSION

23. PRIOR AUTHORIZATION NUMBER

C A

R R

IE R

P A

TI E

N T

A N

D IN

S U

R E

D IN

FO R

M A

TI O

N P

H Y

S IC

IA N

O R

S U

P P

LI E

R IN

FO R

M A

TI O

M F

YES NO

I. K.

(Explain Unusual Circumstances) CPT/HCPCS MODIFIER

SEX MM DD YY

YES NO

PLACE (State)

GROUP HEALTH PLAN

FECA BLK LUNG

6. PATIENT RELATIONSHIP TO INSURED

8. RESERVED FOR NUCC USE

b. RESERVED FOR NUCC USE

c. RESERVED FOR NUCC USE c. OTHER ACCIDENT?

10d. CLAIM CODES (Designated by NUCC)

Self Spouse Child Other

(Medicare#) (Member ID#) (ID#) (ID#)

( )

ICD Ind.

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.

32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #

NUCC Instruction Manual available at: www.nucc.org

c. INSURANCE PLAN NAME OR PROGRAM NAME

17b. NPI

a. b. a. b.

NPI

NPI NPI

( )

OMB APPROVAL PENDINGPLEASE PRINT OR TYPE

complete items 9, 9a, and 9d.

D R A F T - N O T F O R O F F I C I A L U S E

APPROVED BY NATIONAL UNIFOR MCLAIM COMMITTEE (NUCC) 02/12

(ID#) 1a. INSURED’S I.D. NUMBER

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

7. INSURED’S ADDRESS (No., Street)

11. INSURED’S POLICY GROUP OR FECA NUMBER 10. IS PATIENT’S CONDITION RELATED TO:

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

5. PATIENT’S ADDRESS (No., Street)

TELEPHONE (Include Area Code)

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

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous)

b. AUTO ACCIDENT?

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

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

12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATUREI 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.

14. DATE OF CURRENT: ILLNESS, INJURY, or PREGNANCY(LMP)

$ CHARGES

24. A. DATE(S) OF SERVICE B. PLACE OF SERVICE

D. PROCEDURES, SERVICES, OR SUPPLIES E. DIAGNOSIS POINTER

G. DAYS

OR UNITS

H. EPSDT Family Plan

I. ID.

QUAL.

J. RENDERING

PROVIDER ID. #

$ CHARGES

EMG

26. PATIENT’S ACCOUNT NO.

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.)

3. PATIENT’S BIRTH DATE

(Medicaid#) (ID#DoD#)

( )

CE’s review

Initials Date

OK Correx.

Author’s review (if needed)

Initials Date

Fordney

Mark if revision

Author ISBN#

9781455733255

BlankredCMS Fig. # Document Name BlankredCMS-

9781455733255 10/27/2012

PMS xxx

Top Graphics 658 Fee Fee Rd. St. Louis, MO 63043

Artist Date

B/W 4/C

Correx.

X X

2/C

10b: Off
10c: Off
1a:
4:
1: Off
3 Sex: Off
2:
6: Off
5b:
5d:
5e:
5c:
5f:
8:
7a:
7c:
7d:
7e:
7b:
7f:
5a:
9a:
9b:
9c:
9d:
9:
10d:
3a:
3b:
3c:
11 Sex: Off
11:
11b 2:
11c:
11 d: Off
11b 1:
10b State:
12 Sig:
12 Date:
13:
11a MM:
11a DD:
11a YY:
14 Qual:
15 Qual:
14 MM:
14 DD:
14 YY:
15 MM:
15 DD:
15 YY:
16 from MM:
16 from DD:
16 from YY:
16 to MM:
16 to DD:
16 to YY:
18 from MM:
18 from DD:
18 from YY:
18 to MM:
18 to DD:
18 to YY:
17a 2:
17b 2:
19:
20: Off
20 charges 1:
20 charges 2:
21e:
21f:
21g:
21h:
21b:
21c:
21d:
21i:
21j:
21k:
21l:
22a:
22b:
23:
24a1 from MM:
24a1 from DD:
24a1 from YY:
24a1 to MM:
24a1 to DD:
24a1 to YY:
24b1:
24c1:
24d1 cpt:
24d1 mod_a:
24d1 mod_b:
24d1 mod_c:
24d1 mod_d:
24e1:
24f1 dollar:
24f1 cents:
24g1:
24j1:
24a2 from MM:
24a2 from DD:
24a2 from YY:
24a2 to MM:
24a2 to DD:
24a2 to YY:
24b2:
24c2:
24d2 cpt:
24d2 mod_a:
24d2 mod_b:
24d2 mod_c:
24d2 mod_d:
24e2:
24f2 dollar:
24f2 cents:
24g2:
24j2:
10a: Off
24a3 from MM:
24a3 from DD:
24a3 from YY:
24a3 to MM:
24a3 to DD:
24a3 to YY:
24b3:
24c3:
24d3 cpt:
24d3 mod_a:
24d3 mod_b:
24d3 mod_c:
24d3 mod_d:
24e3:
24f3 dollar:
24f3 cents:
24g3:
24j3:
24a4 from MM:
24a4 from DD:
24a4 from YY:
24a4 to MM:
24a4 to DD:
24a4 to YY:
24b4:
24c4:
24d4 cpt:
24d4 mod_a:
24d4 mod_b:
24d4 mod_c:
24d4 mod_d:
24e4:
24f4 dollar:
24f4 cents:
24g4:
24j4:
24a5 from MM:
24a5 from DD:
24a5 from YY:
24a5 to MM:
24a5 to DD:
24a5 to YY:
24b5:
24c5:
24d5 cpt:
24d5 mod_a:
24d5 mod_b:
24d5 mod_c:
24d5 mod_d:
24e5:
24f5 dollar:
24f5 cents:
24g5:
24j5:
24a6 from MM:
24a6from DD:
24a6 from YY:
24a6 to MM:
24a6 to DD:
24a6 to YY:
24b6:
24c6:
24d6 cpt:
24d6 mod_a:
24d6 mod_b:
24d6 mod_c:
24d6 mod_d:
24e6:
24f6 dollar:
24f6 cents:
24g6:
24j6:
25 ID:
25: Off
26:
27: Off
28 dollar:
28 cent:
29 dollar:
29 cent:
30 dollar:
30 cent:
31 sig:
31 date:
24h1:
24h2:
24h3:
24h4:
24h5:
24h6:
24i1:
24i2:
24i3:
24i4:
24i5:
24i6:
32:
32a:
32b:
33:
33 prefix:
33 phone:
33a:
33b:
17a 1:
17b 1:
17a:
17b:
21a:
21 ICD a:
21 ICD b:
nothing: