Please do not staple in this area CMS 1500 - (formerly L&I Health Ins Claim form) APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 CARRIER DEPARTMENT OF LABOR AND INDUSTRIES CLAIMS SECTION PO BOX 44269 OLYMPIA WA 98504-4269 PICA PICA MEDICARE MEDICAID (Medicare #) TRICARE CHAMPUS (Sponsor’s SSN) (Medicaid #) GROUP HEALTH PLAN (SSN or ID) CHAMPVA (Member ID#) 3. PATIENT’S BIRTH DATE MM DD YY 2. PATIENT’S NAME (Last Name, First Name, Middle Initial) OTHER 1a. INSURED’S I.D. NUMBER FECA BLK LUNG (SSN) (ID) 4. INSURED’S NAME (Last Name, First Name, Middle Initial) SEX M 5. PATIENT’S ADDRESS (No., Street) F 6. PATIENT RELATIONSHIP TO INSURED Self CITY STATE Child Spouse 8. PATIENT STATUS STATE CITY Married Other Employed Full-Time Student Part-Time Student TELEPHONE (Include Area Code) ( 7. INSURED’S ADDRESS (No., Street) Other Single ZIP CODE (For Program in Item 1) ZIP CODE ) TELEPHONE (Include Area Code) ( ) 9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH MM DD YY b. OTHER INSURED’S DATE OF BIRTH MM DD YY b. AUTO ACCIDENT? SEX PLACE (State) c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME NO YES d. INSURANCE PLAN NAME OR PROGRAM NAME d. IS THERE ANOTHER HEALTH BENEFIT PLAN? 10d. RESERVED FOR LOCAL USE YES 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 14. DATE OF CURRENT: MM DD YY NO If yes, return to and complete item 9 a-d. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. DATE ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY(LMP) F b. EMPLOYER’S NAME OR SCHOOL NAME NO YES F M SEX M NO YES PATIENT AND INSURED INFORMATION 1. SIGNED 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION DD YY MM DD YY MM DD YY GIVE FIRST DATE MM FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO 17a. 17b. NPI 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? YES 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 1. $ CHARGES NO 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 3. 2. 24. A. MM DATE(S) OF SERVICE From To DD YY MM DD YY B. C. PLACE OF SERVICE EMG 4. D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER E. DIAGNOSIS POINTER F. $ CHARGES H. G. I. J. RENDERING PROVIDER ID. # EPSDT ID. Family Plan QUAL. DAYS OR UNITS 1 NPI 2 NPI 3 NPI 4 NPI 5 NPI 6 NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? (For govt. claims, see YES 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. NUCC Instruction Manual available at: www.nucc.org NPI b. back) NO 28. TOTAL CHARGE $ 29. AMOUNT PAID 33. BILLING PROVIDER INFO & PH # a. 30. BALANCE DUE $ NPI $ ( ) b. APPROVED OMB-0938-0999 FORM CMS-1500 (08/05) F245-127-000 08-05 American LegalNet, Inc. www.FormsWorkflow.com PHYSICIAN OR SUPPLIER INFORMATION 23. PRIOR AUTHORIZATION NUMBER