Fillable Submission of this claim form does not guarantee (Sanford Health Plan)

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Submission of this claim form does not guarantee (Sanford Health Plan)

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  • 8 check-boxes
  • 124 other fields

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File type: PDF

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HP-0055 02/17
SECTION 1
SECTION 2
PATIENT AND INSURED INFORMATION
PHYSICIAN OR SUPPLIER INFORMATION
Member instructions: Complete and sign section one and give to your provider to complete section two.
Submission of this claim form does not guarantee payment of services. Claims may be delayed for missing information.
Submit completed form, along with applicable receipts or itemized statements and proof of payment to Sanford Health Plan
at the address above.
Subscriber and Patient Information
Patient’s Name:
Subscriber I.D. Number:
Patient’s Address:
Subscriber’s Name:
City:
State:
Subscriber’s Address:
Telephone:
City:
State:
Patient’s Birth Date:
Gender:
□ M □ F
Patient Relationship to Subscriber
□ Self □ Spouse □ Child □ Other
Zip Code
Telephone:
Subscriber’s Employer:
Are services for a work related injury?
□ Yes □ No
Patient’s or Authorized Person’s Signature:
I authorize the release of any medical or other information necessary to process this claim
Signed__________________________________________________
Date Signed:
Date of Accident:
Referring Physician NPI:
Diagnosis Code:
A. _____________________
E. _____________________
I. ______________________
B. ______________________
F. ______________________
J. ______________________
C. ______________________
G. ______________________
K. ______________________
D. ______________________
H. ______________________
L. ______________________
Place
Of
Service
Procedures, Services,
or Supplies
CPT/HCPCS Modifier
Description of Services
Diagnosis
Pointer
Charges
Days
or
Units
Rendering
Provider
I.D. Number
From:
To:
MM
DD
YY
MM
DD
YY
Federal Tax I.D. Number SSN EIN
□ □
Patient’s Account No.:
Total Charge:
Signature of Physician or Supplier including
degrees or credentials:
Signed_____________________________
Date______________________________
Service Facility Location Information:
Billing Provider Info and Phone Number:
Facility NPI:
Billing NPI:
PO Box 91110
Sioux Falls, SD 57109
(877) 305-5463
Fax: (605) 328-6811
sanfordhealthplan.com
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Submission of this claim form does not guarantee (Sanford Health Plan)

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Completed 20 May 2021

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