Out Of Network Claim Form
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2OUT-OF-NETWORK CLAIM FORM
DMC CARE - DMC
PATIENT INFORMATION (To Be Completed by Employee)
EMPLOYEE INFORMATION
1. PATIENT'S NAME (First, middle initial, & last name)
2. PATIENT'S DATE OF BIRTH
3. EMPLOYEE'S NAME, ADDRESS, & PHONE NO.
FULL-TIME STUDENT
YES
NO
(If YES, where)
6. EMPLOYEE'S SOC. SEC. NO.
4. PATIENT'S ADDRESS (If different from employee)
5. PATIENT'S SEX
MALE
FEMALE
8. FACILITY NAME
9. IS SPOUSE EMPLOYED?
NO
YES (If YES, give
7. PATIENT'S RELATIONSHIP
spouse's employer name & address)
SELF
SPOUSE
12. IF AN ACCIDENT
AM
CHILD
OTHER
DATE ____ 20 ____ AND TIME _____
PM
11. WAS CONDITION RELATED TO DESCRIPTION (HOW & WHERE)____________________________________
10. ARE YOU, YOUR SPOUSE OR YOUR DEPENDENT
A. PATIENT'S EMPLOYMENT
CHILDREN ENTITLED TO BENEFITS UNDER
YES
NO
A. ANY OTHER GROUP HEALTH OR WELFARE PLAN
B. AN ACCIDENT
YES
NO
YES
NO
B. MEDICARE
YES
NO
13. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE
14. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED
I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS
PHYSICIAN OR SUPPLIER FOR SERVICE BELOW.
THIS REQUEST.
SIGNED
SIGNED
DATE
(EMPLOYEE)
PHYSICIAN OR SUPPLIER INFORMATION (Complete, fold, and mail)
15. PATIENT'S NAME (First name, middle initial, last name)
16. DATE OF ILLINESS (FIRST SYMPTOM) OR INJURY
17. DATE FIRST CONSULTED YOU 18. HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS
(ACCIDENT) OR PREGNANCY (LMP) _______________
FOR THIS CONDITION ___________
YES
NO
19. DATE PATIENT ABLE TO
20. DATES OF TOTAL DISABILITY
DATES OF PARTIAL DISABILITY
RETURN TO WORK ______________
FROM
THRU
FROM
THRU
21. NAME OF INITIAL TREATING PHYSICIAN
22. FOR SERVICES RELATED TO HOSPITALIZATION
GIVE HOSPITALIZATION DATES
ADMITTED
DISCHARGED
23. NAME & ADDRESS OF FACILITY WHERE SERVICES RENDERED (If other than home or office) 24. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR
OFFICE?
YES
NO
CHARGES
25. DIAGNOSIS OR NATURE OF ILLNESS/ INJURY - RELATE DIAGNOSIS TO PROCEDURE IN COLUMN BY REFERENCE TO NUMBERS 1. 2. 3. ETC OR DX CODE
1.
2.
3.
4.
26.
A.
B.
C. FULLY DESCRIBE PROCEDURES, MEDICAL SERVICES OR SUPPLIES
D.
E.
F.
DATE OF
PLACE
FURNISHED FOR EACH DATE GIVEN
DIAGNOSIS CHARGES
SERVICE
OF
Procedure Code
(Explain unusual services or
CODE
SERVICE* (Identify
)
circumstances)
27. SIGNATURE OF PHYSICIAN OR SUPPLIER
28.
29. TOTAL CHARGE
30. AMOUNT
31. BALANCE
PAID
DUE
33. ENTER TAXPAYER IDENTIFI-
34. PHYSICIAN'S OR SUPPLIER'S NAME, ADDRESS, ZIP CODE &
SIGNED
DATE
CATION NO. TO BE USED FOR
TELEPHONE NO.
32. YOUR PATIENT'S ACCOUNT NO.
1099 REPORTING PURPOSES:
_____________________________
*PLACE OF SERVICE
1. (IH) - INPATIENT HOSPITAL
5. - DAY CARE FACILITY (PSY)
9. - AMBULANCE
2. (OH) - OUTPATIENT HOSPITAL
6. - NIGHT CARE FACILITY (PSY)
0. (OL) - OTHER LOCATIONS
3. (C) - DOCTOR'S OFFICE
7. (NH) - NURSING HOME
A. (IL) - INDEPENDENT LABORATORY
4. (H) - PATIENT'S HOME
8. (SNF) - SKILLED NURSING FACILITY
B. - OTHER MEDICAL/SUPPLY FACILITY
*NOTE TO DOCTOR
APPROVED BY AMA COUNCIL ON MEDICAL SERVICES 6-74
If surgery is suggested, please sign and complete information below:
Signature
Date
In my professional opinion, the surgery is elective
is not elective
and can
cannot
be performed at the patient's convenience
without jeopardizing the patient's life or causing serious impairment to the patient's bodily functions.
Revised 1/04
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