Box Number |
Required Information |
1.a. |
Insured's ID Number |
2. |
Patient's Name |
3. |
Patient's Birth Date |
4. |
Insured's Name |
5. |
Patient's Address |
6. |
Patient Relationship To Insured |
7. |
Insured's Address |
9.a. |
Other Insured's Name (N/A if not applicable) |
9.b. |
Other Insured's Policy Or Group No. |
9.c. |
Employer's Name Or School Name |
9.d. |
Insurance Plan Name Or Program Name |
11.a. |
Insured's Date Of Birth |
11.b. |
Employer's Name Or School Name |
11.c. |
Insurance Plan Name Or Program Name |
11.d. |
Is There Another Health Benefit Plan? |
12. |
Patient's Or Authorized Person's Signature (or indicate signature on file) |
13. |
Insured's Or Authorized Person's Signature (or indicate signature on file) |
21. |
Diagnosis Or Nature of Illness Or Injury |
23. |
Prior Authorization Number |
24.A. |
Date(s) Of Service |
24.B. |
Place Of Service |
24.C. |
Type Of Service |
24.D. |
Procedures, Service Or Supplies (CPT/HCPCS) |
24.E. |
Diagnosis Code |
24.F. |
Charges |
24.G. |
Days Or Units |
25. |
Federal Tax ID Number |
31. |
Signature Of Physician Or Supplier, Including Degrees Or Credentials |
32. |
Name and Address Of Facility Where Services Were Rendered |
33. |
Physician's, Supplier's Billing Name, Address, Zip Code and Phone Number |
