HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE MEDICARE (Medicare#) MEDICAID (Medicaid#) TRICARE (ID#/DoD#) CHAMPVA (Member ID#) GROUP HEALTH PLAN (ID#) FECA BLK LUNG (ID#) OTHER (ID#)1. 1a. INSURED I.D. NUMBER (For Program in Item 1) 2. PATIENT'S NAME (Last, First, Middle Initial) 4. INSURED'S NAME (Last, First, Middle Initial) 3. PATIENT'S BIRTH DATE SEX F M 5. PATIENT'S ADDRESS (Street, City, State, Zip) TELEPHONE (Include Area Code): 7. INSURED'S ADDRESS (Street, City, State, Zip) TELEPHONE (Include Area Code): 6. PATIENT RELATIONSHIP TO INSURED Other Child Spouse Self 9. OTHER INSURED'S NAME (Last, First, Middle Initial) a. OTHER INSURED POLICY OR GROUP NUMBER 8. RESERVED FOR NUCC USE b. RESERVED FOR NUCC USE c. RESERVED FOR NUCC USE d. PATIENT'S PLAN OR PROGRAM NAME 10d. CLAIM CODES (Designated by NUCC) Yes Noa. EMPLOYMENT? (Current or Previous) Yes Nob. AUTO ACCIDENT? Yes Noc. OTHER ACCIDENT?PLACE (State)10. PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER SEX F M a. INSURED'S DATE OF BIRTH b. OTHER CLAIM ID (Designated by NUCC) c. INSURANCE PLAN NAME OR PROGRAM NAME Yes Nod. IS THERE ANOTHER HEALTH BENEFIT PLAN? If yes, complete items 9, 9a, and 9d. 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 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.. SIGNED 14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP) QUAL. 15. OTHER DATE QUAL. FROM:16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION TO: 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 17b. NPI FROM:18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES TO: 19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) Yes No20. OUTSIDE LAB?$ CHARGES A. E. 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24e)I. B. F. J. C. G. K. D. H. L. ICD Ind. 22. RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER 24. A. DATE(S) OF SERVICEFromTo B. PLACE OF SERVICE C. EMG D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPSCSMODIFIER E. DIAGNOSIS POINTER (A-L) F. $ CHARGES G. DAYS OR UNITS H. EPSOT Family Plan I. ID QUAL. J. RENDERING PROVIDER NPI # NPI NPI NPI NPI NPI NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? (For govt. claims, see back) Yes No 28. TOTAL CHARGE$ 29. AMOUNT PAID$ 30. Rsvd for NUCC Use 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.) SIGNED DATE 32. SERVICE FACILITY LOCATION INFORMATION a. b. 33. BILLING PROVIDER INFO & PH # a. b. PATIENT AND INSURED INFORMATION PHYSICIAN OR SUPPLIER INFORMATIONAPPROVED OMB-093B-1197 FORM CMS-1500 (06-15)NUCC instruction Manual available at www.nucc.orgPLEASE PRINT OR TYPEOMB No. 1240-0044 Expires: 06/30/2021 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing OWCP-1500 Health Insurance Claim Form For Medical Services Provided Under the FEDERAL EMPLOYEES' COMPENSATION ACT (FECA), the BLACK LUNG BENEFITS ACT (BLBA), and the ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT of 2000 (EEOICPA) GENERAL INFORMATION-FECA AND EEOICPA CLAIMANTS: Claims filed under FECA (5 USC 8101 et seq.) are for employment-related illness or injury. Claims filed under EEOICPA (42 USC 7384 et seq.) are for compensable illnesses defined under that Act. All services, appliances, and supplies prescribed or recommended by a qualified physician, which the Secretary of Labor considers likely to give relief, reduce the degree or period of the disability or illness, or aid in lessening the amount of the monthly compensation, may be furnished. "Physician" includes all Doctors of Medicine (M.D.), podiatrists, dentists, clinical psychologists, optometrists, chiropractors, or osteopathic practitioners within the scope of their practice as defined by State law. However, the term "physician" includes chiropractors only to the extent that their reimbursable services are limited to treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by x-ray to exist.FEES: The Department of Labor's Office of Workers' Compensation Programs (OWCP) is responsible for payment of all reasonable charges stemming from covered medical services provided to claimants eligible under FECA and EEOICPA. OWCP uses a relative value scale fee schedule and other tests to determine reasonableness. Schedule limitations are applied through an automated billing system that is based on the identification of procedures as defined in the AMA's Current Procedural Terminology (CPT); correct CPT code and modifier(s) is required. Incorrect coding will result in inappropriate payment. For specific information about schedule limits, call the Dept. of Labor's Federal Employees' Compensation office or Energy Employees Occupational Illness Compensation office that services your area.REPORTS: A medical report that indicates the dates of treatment, diagnosis(es), findings, and type of treatment offered is required for services provided by a physician (as defined above). For FECA claimants, the initial medical report should explain the relationship of the injury or illness to the employment. Test results and x-ray findings should accompany billings.GENERAL INFORMATION-BLBA CLAIMANTS: The BLBA (30 USC 901 et seq.) provides medical services to eligible beneficiaries for diagnostic and therapeutic services for black lung disease as defined under the BLBA. For specific information about reimbursable services, call the Department of Labor's Black Lung office that services your facility or call the National Office in Washington, D.C. SIGNATURE OF PHYSICIAN OR SUPPLIER: Your signature in Item 31 indicates your agreement to accept the charge determination of OWCP on covered services as payment in full, and indicates your agreement not to seek reimbursement from the patient of any amounts not paid by OWCP for covered services as the result of the application of its fee schedule or related tests for reasonableness (appeals are allowed). Your signature in Item 31 also indicates that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by you or were furnished incident to your professional services by your employee under your immediate personal supervision, except as otherwise expressly permitted by FECA, Black Lung or EEOICPA regulations. For services to be considered as "incident" to a physician's professional service, 1) they must be rendered under the physician's immediate personal supervision by his/her employee, 2) they must be an integral, although incidental, part of a covered physician's service, 3) they must be of kinds commonly furnished in physician's offices, and 4) the services of non-physicians must be included on the bills. Finally, your signature indicates that you understand that any false claims, statements or documents, or concealment of a material act, may be prosecuted under applicable Federal or State laws.NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF FECA, BLACK LUNG AND EEOICPA INFORMATION (PRIVACY ACT STATEMENT) We are authorized by OWCP to ask you for information needed in the administration of the FECA, Black Lung and EEOICPA programs. Authority to collect information is in 5 USC 8101 et seq.; 30 USC 901 et seq.; 38 USC 613; E.O. 9397; and 42 USC 7384d, 20 CFR 30.11 and E.O. 13179. The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility. It is also used to decide if the services and supplies you received are covered by these programs and to insure that proper payment is made. Your response regarding the medical service(s) received or the a