REQUESTFOR MEDICARE PAYMENT AMBULANCE MEDICALINSURANCE BENEFITS - SOCIALSECURITYACT (SEE INSTRUCTIONS ON BACK - TYPE OR PRINTINFORMATION) FORM APPROVED OMB NO 0938-0042 PART 1 PATIENTTO FILL IN ITEMS 1 THROUGH 6 ONLY No Part B Medicare Benefits may be paid unless a completed application form has been received as required by existing law and regulations (20 C.F.R. 405-251). NOTICE Anyone who misrepresents or falsifies essential information requested by this form may upon conviction be subject to fine and imprisonment under Federal law. COPY FROM 1 Name of Patient (First Name, Middle Initial, Last Name) YOUR OWN HEALTH INSURANCE 2 Health Insurance Claim No. Male CARD(See Example on Back) Female Patient s complete mailing address (including Apt. No.)City, State, ZIPcode Telephone Number 3 ( ) Was your illness or injury: Yes No 4 a. Connected with your employment? b. Result of an auto accident? c. Result of other type accident? 5 If any of your medical expenses will be or could be paid by another insurance organization or government agency, show below Name and address of organization or agency Policy or Identification Number Note: If you Do Not want information about this Medicare claim released to the above upon request, check (X) the following block I authorize any holder of medical or other information about me to release to the Social Security Administration and Centers for Medicare & 6 Medicaid Services or its intermediaries or carriers any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment below.Signature of patient (See instructions on reverse where patient is unable to sign) Date signed SIGN HERE PART II AMBULANCE SUPPLIER TO FILLIN 7 THROUGH 25 7. Date of Service Emergency Admission 8. Ordered By Discharge Outpatient visit 9. Description of Illness or Injury (Describe factors which made ambulance transportation necessary) 10. Name of Treating Doctor 11. Address and Telephone Number of Doctor 12. Origin of Service 13. Destination of Service 14. Number of Miles 15. Cost per Mile 16. Mileage Charge 22. Describe special service (no none leave blank) 17. Base Rate 18. Spec. Serv. Chg. (Desc. Item 22) 23. Name and Address of Supplier (Number and Street, City, Supplier Code 19. Total State, ZIP Code) Charges 20. Amount Paid Telephone Number 21. Any Unpaid () Balance Due 24. Assignment of Patient s Bill I accept assignment (See reverse) I do not accept assignment 25. Signature of Supplier Date SignedCMS-1491 (SC) (01/89) DEPARTMENTOF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES>>>> 2SOME THINGS TO NOTE IN FILLING OUT PART I(Your supplier will fill out Part II). & Copy the name and number and indicate 1 2 your sex exactly as shown on your health insurance card,include the letters at the end of the number. Enter your mailing address and telephone 3 number, if any. Be sure to check one of the two boxes. 4 If you have other health insurance or expect 5 a welfare agency to pay part of the expenses, complete item 5. Be sure to sign your name. If you cannot 6 write your name,sign by mark (X),and have a witness sign his/her name and enter his/her address on this line. If the claim is filed for the patient by another person,he or she should enter the patients name and write By, sign his/her own name and address in this space,show his/her relationship to the patient,and why the patient cannot sign. (If the patient has died,the survivor should contact any social security office for information on what to do).IMPORTANT NOTES FOR PHYSICIANS AND SUPPLIERS Item 24:In assigned cases the patient is responsible only for thedeductible,coinsurance,and non-covered services. Coinsuranceand the deductible are based upon the charge the carrier determinesto be reasonable if this is less than the charge submitted.If the physician or supplier does not want Part II information released to the organization named in item 5,he or she should write No further release in Item 22. COLLECTION AND USE OF MEDICARE INFORMATIONWe are authorized by the Centers for Medicare & Medicaid Services to ask you for information needed in the administration of theMedicare program. Authority to collect information is in section 205(a),1872 and 1875 of the Social Security Act, as amended.The information we obtain to complete your Medicare claim is used to identify you and to determine your eligibility. It is also usedto decide if the services and supplies you received are covered by Medicare and to insure that proper payment is made. r- The infomation may also be given to other providers of services,carriers,intermediaries,medical review boards,and other organizationsas necessary to administer the Medicare program. For example,it may be necessary to disclose information about the Medicarebenefits you have used to a hospital or doctor.With one exception,which is discussed below, there are no penalties under social security law for refusing to supply information.However, failure to furnish information regarding the medical services rendered or the amount charged would prevent payment ofthe claim. Failure to furnish any other information,such as name or claim number, would delay payment of the claim.It is mandatory that you tell us if you are being treated for a work related injury so we can determine whether w s com-orkmenpensation will pay for the treatment. Section 1877(a)(3) of the Social Security Act provides criminal penalties for withholding thisinformation. According to the Paperwork Reduction Act of 1995,no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for thisinformation collection is 0938-0042. The time required to complete this information collection is estimated to average 10 minutes per response,including the time to review instructions,searching existingdata resources,gather the data needed,and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving thisform,please write to:CMS,Attn:PRAReports Clearance Officer, 7500 Security Boulevard,Baltimore,Maryland 21244-1850.