www.nucc.org
APPROVED BY NATIONAL UNIFORM CLAIM
PICA
PICA
1
2
3
4
5
6
NPI
NPI
( )
17a.
I.
17b. NPI
M
1a. INSURED’S I.D. NUMBER
13. INSURED'S OR AUTHORIZED PERSON’S SIGNATURE
payment of medical benefits to the undersigned physician or supplier for
services described below.
14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP)
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE
to process this claim. I also request
be
low
.
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
15. OTHER DATE
SIGNED
SIGNED
DATE
c. OTHER ACCIDENT?
YES NO
PLACE (State)
b.
RESERVED FOR NUCC USE
Self
M F
3. PATIENT’S BIRTH DATE
MM DD YY
J.
RENDERING
PROVIDER ID. #
YES NO
If yes
, complete items 9, 9a, and 9d.
YES NO
YES NO
1. MEDICARE MEDICAID
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
5. PATIENT’S ADDRESS (No., Street)
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
a. OTHER INSURED’S POLICY OR GROUP NUMBER
c.
RESERVED FOR NUCC USE
6. PATIENT RELATIONSHIP TO INSURED
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
7. INSURED’S ADDRESS (No., Street)
ETATS
YTIC
11. INSURED’S POLICY GROUP OR FECA NUMBER
a. INSURED’S DATE OF BIRTH
( )
b. OTHER CLAIM ID (Designated by NUCC)
c. INSURANCE PLAN NAME OR PROGRAM NAME
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
22. RESUBMISSION
23. PRIOR AUTHORIZATION NUMBER
F.
$ CHARGES
G.
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E)
24. A.
B.
C.
EMG
D. PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
MODIFIER
CPT/HCPCS
E.
DIAGNOSIS
POINTER
For govt. claims, see back
$
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.)
a. EMPLOYMENT? (Current or Previous)
( )
10. IS PATIENT’S CONDITION RELATED TO:
b. AUTO ACCIDENT?
A.
NUCC Instruction Manual available at: www.nucc.org
PLEASE PRINT OR TYPE
APPROVED OMB-0938-1197 FORM 1500 (02-12)
HEALTH INSURANCE CLAIM FORM
(Medicare#)
(Medicaid#) (ID#/DoD#)
(Member
TRICARE
CHAMPVA
GROUP
(ID#)
ID#)
FECA
OTHER
(ID#)
(ID#)
Spouse
Child
Other
ZIP CODE
TELEPHONE (Include Area Code)
MM YY DD
STATE
8. RESERVED FOR NUCC USE
(Include Area Code)
ZIP CODE
CITY
TELEPHONE
d. INSURANCE PLAN NAME OR PROGRAM NAME
I authorize the release
of any medical or other information necessary
payment of government benefits either to myself or to the party who
accepts assignment
MM
YY
DD
10d. CLAIM CODES (Designated by NUCC)
DATE(S) OF SERVICE
From
MM
DD
To
YY
MM
DD
YY
I authorize
MM YY
DD
MM
YY
DD
FROM
MM
YY
DD
TO
MM
YY
DD
FROM
MM
YY
DD
TO
$ CHARGES
20. OUTSIDE LAB?
CODE
YES
NO
ORIGINAL REF. NO.
PLACE OF
SERVICE
DAYS
UNITS
OR
H.
EPSDT
Plan
Family
QUAL.
ID.
NPI
NPI
NPI
NPI
NPI
SIGNED DATE
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT’S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
YES
NO
28. TOTAL CHARGE
$
29. AMOUNT PAID
30. Rsvd.for NUCC Use
33. BILLING PROVIDER INFO & PH #
32. SERVICE FACILITY LOCATION INFORMATION
a.
b.
CARRIER
PATIENT AND INSURED INFORMATION
PHYSICIAN OR SUPPLIER INFORMATION
COMMITTEE (NUCC) 02/12
(For Program in Item 1)
SEX
F
SEX
BLK
HEALTH
PLAN
LUNG
(
)
a.
b.
QUAL.
E.
I.
QUAL.
B.
F.
J.
C.
G.
K.
D.
H.
L.
ICD Ind.
NPI
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886XX0999
SANDOVAL, ROSA, M
11
01
1991
SANDOVAL, HERNAN, J
209 WEST MAPLE STREET
WOODLAND HILLS
XY
12345-0001
4563322
HHC 3RD BATT 25TH INFANTRY
APO NEW YORK
NY
10030
02
10
1970
TRICARE
SOF
SOF
04
28
20XX
05
01
20XX
05
01
20XX
0
H66001
H663X1
2076500781
05
01
XX
11
99202
25
A
51.91
1
37640017XX
05
01
XX
22
69420
RT
A
97.76
1
37640017XX
7132061XX
14-4
149.67
PEDRO ATRICS MD
053120XX
COLLEGE HOSPITAL
4500 BROAD AVENUE
WOODLAND HILLS XY 12345-0001
X950731067
555
4869002
COLLEGE CLINIC
4567 BROAD AVENUE
WOODLAND HILLS XY 12345-0001
3664021CC