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1. Claim Type 1A. Insured's I.D. Number 2. Patient's Name - Last 2. Patient's Name - First 2. Patient's Name - Middle 3. Patient's Date of Birth 3. Patient's Sex 4. Insured's Name - Last 4. Insured's Name - First 4. Insured's Name - Middle 5. Patient's Address - Street 5. Patient's Address - City 5. Patient's Address - State 5. Patient's Address - Zip 6. Patient's Relation to Insured 7. Insured's Address - Street 7. Insured's Address - City 7. Insured's Address - State 7. Insured's Address - Zip 9. Other Insured's Name - Last 9. Other Insured's Name - First 9. Other Insured's Name - Middle 9A. Other Insured's Policy or Group # |
9B. Other Insured's Date of Birth 9B. Other Insured's Sex 9D. Other Insured's Plan or Program Name 10. Patient's Condition Related To: 11. Insured's Policy or Group # 11A. Insured's Date of Birth 11A. Insured's Sex 11C. Insured's Plan or Program Name 12. Patient's Signature on File 13. Insured's Signature on File 14. Date of Current Illness 15. Date of Similar Illness 16. Date Unable to Work - Begin 16. Date Unable to Work - End 17. Referring Physician's Name - Last 17. Referring Physician's Name - First 17. Referring Physician's Name - Middle 17A. Referring Physician's I.D. Number 18. Hospitalization Date - Begin 18. Hospitalization Date - End 20. Outside Lab Charges 21. Diagnosis Code 22. Medicaid Resubmission - Original Reference # |
23. Prior Authorization # 25. Federal Tax I.D. Number 26. Patient Account # 27. Accepted Assignment 28. Total Charge 29. Amount Paid 30. Balance Due 31. Physician's or Supplier's Signature on File 32. Facility Name 32. Facility Address - Street 32. Facility Address - City 32. Facility Address - State 32. Facility Address - Zip 33. Billing Name 33. Billing Address - Street 33. Billing Address - City 33. Billing Address - State 33. Billing Address - Zip 33. Pin # 33. Group # Clearinghouse Trace Number First Service Date |