hcr220r3_Appendix_C final pt1

hcr220r3_Appendix_C final pt1 - Appendix C MEDICAID...

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Appendix C 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER CHAMPUS HEALTH PLAN BLK LUNG (Medicare #) (Medicaid #) (Sponsor’s SSN) (Member ID #) (SSN or ID) (SSN) (ID) 1a. INSURED’S I.D. # (For Program in Item 1) 3. PATIENT’S BIRTH DATE SEX 2. PATIENT’S NAME (Last Name, First Name, MI) MM DD YY M F 4. INSURED’S NAME (Last Name, First Name, MI) 5. PATIENT’S ADDRESS ( #, Street) 6. PATIENT RELATIONSHIP TO INSURED Self Spouse Child Other 7. INSURED’S ADDRESS ( #, Street) CITY STATE CITY STATE ZIP CODE TELEPHONE (Include Area Code) ( ) 8. PATIENT STATUS Single Married Other Employed Full-Time Part-Time Student Student ZIP CODE TELEPHONE (Include Area Code) ( ) 9. OTHER INSURED’S NAME (Last Name, First Name, MI) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA # a. INSURED’S DATE OF BIRTH SEX a. OTHER INSURED’S POLICY OR GROUP # a. EMPLOYMENT? (Current of Previous) YES NO MM DD YY M F b. INSURED’S DATE OF BIRTH SEX PLACE (State) MM DD YY M F b. AUTO ACCIDENT?
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