PICA
B.
PLACE OF
SERVICE
1a. INSURED’S I.D. NUMBER
(For Program in Item 1)
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
7. INSURED’S ADDRESS (No., Street)
CITY
STATE
ZIP CODE
TELEPHONE (Include Area Code)
11. INSURED’S POLICY GROUP OR FECA NUMBER
a. INSURED’S DATE OF BIRTH
b. OTHER CLAIM ID (Designated by NUCC)
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.
SEX
HEALTH INSURANCE CLAIM FORM
OTHER
1. MEDICARE
MEDICAID TRICARE
CHAMPVA
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 DATE
MM DD YY
15.OTHER DATE
MM DD YY
14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP)
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
1
2
3
4
5
6
25. FEDERAL TAX I.D. NUMBER SSN EIN
26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?
(For govt. claims, see back)
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
SIGNED
MM
DD
YY
FROM
TO
FROM TO
MM DD YY
MM DD YY
MM DD YY MM DD YY
CODE
ORIGINAL REF. NO.
$ CHARGES
28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
$
$
PICA
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
5. PATIENT’S ADDRESS (No., Street)
CITY STATE
ZIP CODE TELEPHONE
(Include Area Code)
9. OTHER INSURED’S NAME
(Last Name, First Name, Middle Initial)
a. OTHER INSURED’S POLICY OR GROUP NUMBER
b. RESERVED FOR NUCC USE
c. RESERVED FOR NUCC USE
d. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
( )
If yes, complete items 9, 9a and 9d.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
20. OUTSIDE LAB?
$ CHARGES
22. RESUBMISSION
23. PRIOR AUTHORIZATION NUMBER
CARRIER
PHYSICIAN OR SUPPLIER INFORMATION
(ID#/DoD#)
M
F
YES NO
YES NO
DATE(S) OF SERVICE
D.PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
DIAGNOSIS
POINTER
FM
SEX
MM DD YY
YES
NO
YES
NO
YES
NO
PLACE (State)
GROUP
HEALTH PLAN
FECA
BLK LUNG
3. PATIENT’S BIRTH DATE
6. PATIENT RELATIONSHIP TO INSURED
8. RESERVED FOR NUCC USE
10. IS PATIENT’S CONDITION RELATED TO:
a. EMPLOYMENT? (Current or Previous)
b. AUTO ACCIDENT?
c. OTHER ACCIDENT?
10d. RESERVED FOR LOCAL USE
Self Spouse Child Other
(Medicare #) (Medicaid #)
(Member ID#)
(ID#) (ID#)
(ID#)
(
DAYS
OR
UNITS
F.
H.
I. J.24. A.
C. E.
PROVIDER ID. #
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
17a.
EMG
RENDERING
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
71b.
NPI
a. b.
a. b.
NPI
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
G.
EPSDT
Family
Plan
ID.
QUAL.
( )
APPROVED OMB-0938-1197 FORM CMS-1500 (02-12)
MODIFIER
MDWizards.com
)
NPI
NPI
NPI
NPI
NPI
$
PATIENT AND INSURED INFORMATION
A.
E.
I.
B.
F.
J.
PLEASE PRINT OR TYPE
C.
G.
K.
D.
H.
L.
QUAL.
QUAL.
ICD Ind.
