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CMS 1500 - (Formerly L And I Health Ins Claim Form) F245-127-000 - Washington

CMS 1500 - (Formerly L And I Health Ins Claim Form) Form. This is a Washington form and can be used in Claims Workers Comp .
 Fillable pdf Last Modified 3/10/2008
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PICA 1. MEDICARE MEDICAID CHAMPUS CHAMPVA PICA GROUP HEALTH PLAN (SSN or ID) (Medicare #) (Medicaid #) (Sponsor's SSN) (VA File #) 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 5. PATIENT'S ADDRESS (No., Street) 3. PATIENT'S BIRTH DATE MM DD YY M FECA BLK LUNG (SSN) OTHER 1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1) (ID) F 6. PATIENT RELATIONSHIP TO INSURED Self SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) 7. INSURED'S ADDRESS (No., Street) Single ZIP CODE TELEPHONE (Include Area Code) Married Full-Time Student Other Part-Time Student ZIP CODE TELEPHONE (INCLUDE AREA CODE) ( ) Employed ( a. INSURED'S DATE OF BIRTH MM DD YY M b. EMPLOYER'S NAME OR SCHOOL NAME ) 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) YES NO PLACE (State) b. OTHER INSURED'S DATE OF BIRTH MM DD YY M c. EMPLOYER'S NAME OR SCHOOL NAME SEX F b. AUTO ACCIDENT? SEX F c. OTHER ACCIDENT? YES YES NO NO c. INSURANCE PLAN NAME OR PROGRAM NAME d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? 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 14. DATE OF CURRENT: MM DD YY ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY(LMP) DATE 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. YES NO If yes, return to and complete item 9 a-d. SIGNED 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION DD YY MM DD YY MM DD YY GIVE FIRST DATE MM FROM TO 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO 20. OUTSIDE LAB? $ CHARGES NO 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 19. RESERVED FOR LOCAL USE 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 1. 3. 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER YES MM 1 DATE(S) OF SERVICE To From MM DD DD YY DIAGNOSIS CODE $ CHARGES COB RESERVED FOR LOCAL USE 2 3 4 5 6 25. FEDERAL TAX I.D. NUMBER SSN EIN 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.) 27. ACCEPT ASSIGNMENT? (For govt. claims, see back) YES NO 28. TOTAL CHARGE $ 29. AMOUNT PAID $ 30. BALANCE DUE $ 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED (If other than home or office) 33. PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE PHONE #: SIGNED DATE PIN# GRP# (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE F245-127-000 10-04 APPROVED OMB-0938-0008 FORM CMS-1500 (12/90), FORM RRB-1500, F FORM RRB-1500 CMS 1500 - (formerly L&I Health Ins ClaimORM OWCP-1500 APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS) American LegalNet, Inc. www.USCourtForms.com PHYSICIAN OR SUPPLIER INFORMATION 2. 24. A 4. B C D Place Type PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) of of YY Service Service CPT/HCPCS MODIFIER E F G H I DAYS EPSDT OR Family EMG UNITS Plan J K PATIENT AND INSURED INFORMATION CITY STATE 8. PATIENT STATUS Spouse Child Other CITY STATE CARRIER PLEASE DO NOT STAPLE IN THIS AREA CMS 1500 - (formerly L&I Health Ins Claim form) DEPARTMENT OF LABOR AND INDUSTRIES CLAIMS SECTION PO BOX 44269 OLYMPIA WA 98504-4269
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