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New York State Government Employees Health Insurance Program

1500 HEALTH INSURANCE CLAIM FORM

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

PICA 1. MEDICARE

(Medicare #)

MEDICAID

(Medicaid #)

TRICARE CHAMPUS

(Sponsor’s SSN)

CHAMPVA

(VA File #)

GROUP HEALTH PLAN

(SSN or ID)

FECA BLK LUNG

OTHER

(SSN)

(ID)

1a. INSURED’S I.D. NUMBER

PICA (For Program In Item 1)

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

5. PATIENT’S ADDRESS (No., Street)

MM 3. PATIENT’S BIRTH DATE DD Y M 6. PATIENT RELATIONSHIP TO INSURED SEX F

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

7. INSURED’S ADDRESS (No., Street)

CITY

STATE

Self Spouse 8. PATIENT STATUS

Child

Other

CITY

STATE

ZIP CODE

TELEPHONE (Include Area Code)

(

)

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

Employed

Full-Time

Part-Time

Student

Student

Single

Married

Other

10. IS PATIENT’S CONDITION RELATED TO:

ZIP CODE

TELEPHONE (Include Area Code)

(

)

11.3INSURED’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

SEX

YES

NO

M

F

b. OTHER INSURED’S BIRTH DATE

MM

DD

YY

M

SEX

F

b. AUTO ACCIDENT? YES

NO

PLACE (State)

b. EMPLOYER’S NAME OR SCHOOL NAME

c. EMPLOYER’S NAME OR SCHOOL NAME

d. INSURANCE PLAN NAME OR PROGRAM NAME

c. OTHER ACCIDENT? YES

NO

c. INSURANCE PLAN NAME OR PROGRAM NAME

EMPIRE PLAN

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. 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.

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

SIGNED

14. DATE OF CURRENT:

MM

DD

YY

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

DATE

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.

GIVE FIRST DATE

MM

DD

YY

SIGNED 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION.

MM

DD

YY

MM

DD

YY

FROM

TO

17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE

19. RESERVED FOR LOCAL USE

17a. 17b.

NPI

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES.

MM

DD

YY

MM

DD

YY

FROM 20. OUTSIDE LAB? YES

NO

TO $ CHARGES

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1, 2, 3 OR 4 TO ITEM 24E BY LINE)

22. MEDICAID RESUBMISSION CODE

ORIGINAL REF. NO.

1.

2. 24. A

MM

. .

DATE(S) OF SERVICE

From

To

DD

YY

MM

DD

3.

.

4.

.

YY

B Place of Service

C

EMG

D PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances)

CPT/HCPCS MODIFIER

G

H

I

DAYS

EPSDT

ID

OR

Family

QUAL

UNITS

Plan

23. PRIOR AUTHORIZATION NUMBER

J

RENDERING PROVIDER ID. #

E

DIAGNOSIS POINTER

F $ CHARGES

1

NPI

NPI

2

NPI

3

NPI

4

NPI

5

26. PATIENT’S ACCOUNT N0.

27. ACCEPT ASSIGNMENT? (For govt. claims, see back)

32. SERVICE FACILITY INFORMATION

YES NO

6

25. FEDERAL TAX I.D. NUMBER

SSN EIN

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.)

28. TOTAL CHARGE

$

$

33. BILLING PROVIDER INFO & PH #

(

NPI

29. AMOUNT PAID

30. BALANCE DUE

$ )

SIGNED DATE

a.

b.

a.

b.

NUCC Instruction Manual available at: www.nucc.org

APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)

CARRIER

PATIENT AND INSURED INFORMATION

PHYSICIAN OR SUPPLIER INFORMATION

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