Medical Claim Form

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1. MEDICAID
1a. INSURED'S I.D. NUMBER
2. PATIENT'S NAME (Last Name, First Name)
3. PATIENT'S BIRTH DATE
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
5. PATIENT'S ADDRESS
6. PATIENT'S RELATIONSHIP TO INSURED
8. RESERVED FOR NUCC USE
7. INSURED'S ADDRESS
9. OTHER INSURED'S NAME
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
10. IS PATIENT'S CONDITION RELATED TO:
a. EMPLOYMENT? (Current or Previous)
b. AUTO ACCIDENT?
c. OTHER ACCIDENT?
10d. CLAIM CODES (Enter Carrier Codes)
11. INSURED'S POLICY GROUP OR FECA NUMBER
a. INSURED'S BIRTH DATE
SEX
b. OTHER CLAIM ID (Designated by NUCC)
c. INSURANCE PLAN NAME OR PROGRAM NAME
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE
I authorize the release of any medical or other information necessary to process this claim.
SIGNED
DATE
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE
I authorize payment of medical benefits to the undersigned physician or supplier.
SIGNED
14. DATE OF CURRENT ILLNESS / INJURY / PREGNANCY (LMP)
15. OTHER DATE
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
17a. G2 / 17b. NPI
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
19. ADDITIONAL CLAIM INFORMATION (Enter Patient Responsibility)
20. OUTSIDE LAB
$ CHARGES
22. RESUBMISSION CODE
ORIGINAL REF. NO.
23. PRIOR AUTHORIZATION NUMBER
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
ICD:
24A.
Date(s) of Service
From / To 		24B.
Place of Service		 24C.
EMG		 24D.
Procedures / Services / Supplies
CPT/HCPCS + Modifier 		24E.
Diagnosis Pointer		 24F.
$ Charges		 24G.
Days / Units		 24H.
EPSDT / Family Plan		 24I.
ID Qual		 24J.
Rendering Provider ID #
25. FEDERAL TAX I.D. NUMBER
SSN / EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. Rsvd for NUCC Use
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.
Date
32. SERVICE FACILITY LOCATION INFORMATION
33. BILLING PROVIDER INFO & PHONE NUMBER