|
1. Medicare Medicaid Champus Champva Group Health
Plan FECA BLK
Lung Other
|
| 1a. Insured's Id. Number |
|
2. Patients Name
|
3. Patients Birth Date
Sex Male Female |
| 4.
Insured's Name |
|
| 5.
Patient's Address |
City |
| State Zip |
Telephone (include area
code) |
| 6.
Patient Relationship to Insured Self Spouse Child
Other |
| 7.
Insured's Address |
City |
| State Zip |
Telephone (include area code) |
| 8. Patient Status Single Married Other Employed Full-time Student Part-time
Student |
| 9.
Other Insured Name |
|
A. Other Insured's Policy or Group Number
|
B. Other Insured's Date of
Birth
Sex Male Female |
C.
Employer's Name or School Name
|
D.
Insurance Plan Name or Program Name
|
10. Is Patients Condition Related To:
|
A. Employment? (Current or Previous) Yes
No |
| B. Auto Accident? Yes No
Place(State) |
C. Other Accident? Yes No |
11.
Insured's Policy Group or FECA Number
|
A. Insured's Date of Birth
Sex Male Female |
B.
Employer's Name or School Name
|
C.
Insurance Plan Name or Program Name
|
|
D. Is there
Another Health Benefit Plan?
Yes No
If yes. Return to and
complete item 9. a-d
|
|
12. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS
FORM.
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: Date: |
13. INSURED'S OR AUTHORIZED
PERSON'S SIGNATURE
I authorize payment of medical benefits to the
undersigned physician or supplier for services described
below.
Signed: |
|
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