Form 1500 - 2005 Health Insurance Claim Form
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41500
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
PICA
PICA
1a. INSURED’S I.D. NUMBER
1.
MEDICARE
MEDICAID
TRICARE
CHAMPVA
GROUP
FECA
OTHER
(For Program in Item 1)
CHAMPUS
HEALTH PLAN
BLK LUNG
(Medicare #)
(Medicaid #)
(Sponsor’s SSN)
(Member ID#)
(SSN or ID)
(SSN)
(ID)
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
3. PATIENT’S BIRTH DATE
SEX
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
MM
DD
YY
M
F
5. PATIENT’S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED’S ADDRESS (No., Street)
Self
Spouse
Child
Other
CITY
STATE
STATE
8. PATIENT STATUS
CITY
Single
Married
Other
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (Include Area Code)
Full-Time
Part-Time
(
)
(
)
Employed
Student
Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
11. INSURED’S POLICY GROUP OR FECA NUMBER
10. IS PATIENT’S CONDITION RELATED TO:
a. EMPLOYMENT? (Current or Previous)
a. OTHER INSURED’S POLICY OR GROUP NUMBER
a. INSURED’S DATE OF BIRTH
SEX
MM
DD
YY
M
F
NO
YES
b. OTHER INSURED’S DATE OF BIRTH
b. AUTO ACCIDENT?
SEX
b. EMPLOYER’S NAME OR SCHOOL NAME
PLACE (State)
MM
DD
YY
YES
NO
M
F
c. EMPLOYER’S NAME OR SCHOOL NAME
c. OTHER ACCIDENT?
c. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
NO
If yes , return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
SIGNED
DATE
SIGNED
ILLNESS (First symptom) OR
14. DATE OF CURRENT:
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
MM
DD
YY
MM
DD
YY
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE
FROM
TO
PREGNANCY(LMP)
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17a.
MM
DD
YY
MM
DD
YY
FROM
TO
17b. NPI
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
4.
24. A.
B.
C.
D.
PROCEDURES, SERVICES, OR SUPPLIES
E.
F.
G.
H.
I.
J.
DATE(S) OF SERVICE
EPSDT
DAYS
From
To
PLACE OF
(Explain Unusual Circumstances)
DIAGNOSIS
RENDERING
ID.
OR
Family
MM
DD
YY
MM
DD
YY
SERVICE
EMG
CPT/HCPCS
MODIFIER
POINTER
$ CHARGES
PROVIDER ID. #
UNITS
Plan
QUAL.
1
NPI
2
NPI
3
NPI
4
NPI
5
NPI
6
NPI
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT’S ACCOUNT NO.
(
For govt. claims, see back
)
20-8728523
$
$
$
YES
NO
(
)
410 979-2326
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. SERVICE FACILITY LOCATION INFORMATION
33. BILLING PROVIDER INFO & PH #
INCLUDING DEGREES OR CREDENTIALS
CPE Clinic, LLC.
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Michael J. Labellarte, M.D.
711 W. 40th Street #428
Baltimore, MD 21211
NPI
NPI
a.
b.
a.
b.
1659568137
SIGNED
DATE
NUCC Instruction Manual available at:
APPROVED OMB-0938-0999 FORM CMS-1500 (08-05)
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