CMS1500_edit - CARRIER PLEASE DO NOT STAPLE IN THIS AREA...

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3. PATIENT’S BIRTH DATE 6. PATIENT RELATIONSHIP TO INSURED 8. PATIENT STATUS 10. IS PATIENT’S CONDITION RELATED TO: a. EMPLOYMENT? (CURRENT OR PREVIOUS) b. AUTO ACCIDENT? c. OTHER ACCIDENT? 10d. RESERVED FOR LOCAL USE 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. EMPLOYER’S NAME OR SCHOOL NAME c. INSURANCE PLAN NAME OR PROGRAM NAME 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 F HEALTH INSURANCE CLAIM FORM OTHER 1. MEDICARE MEDICAID CHAMPUS 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
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