Claim Form - Figure 3.27

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Use the following information to complete this health insurance claim form. Use the Internet to find the correct medical coding for this diagnosis and determine realistic charges for these services.

A male patient named Robert Blake first went to his doctor, Roy Blanchard, at Better Medical Clinic on January 10, 2015 for an office visit. Robert had a unilateral chest X-ray, which revealed a broken rib due to a car accident on January 8, 2015. There was a follow-up office visit on March 15, 2015. Robert lives at 2400 East Highland Drive, Boland, MN 84672. His phone number is (840) 672-3456. His wife, Shelly, drove him to the clinic. She does not work outside the home. Robert is insured with a signature on file through the Benefit Health Plan, group number 02635. The insurer’s I.D. number is 04635. Robert was born November 11, 1984. The patient account number is 0429 with an accepted assignment federal tax I.D. number 38-0000.000. The billing provider’s phone number is (426) 814-7639. Robert did not pay for any services yet.

HEALTH INSURANCE CLAIM FORM
PATIENT AND INSURED INFORMATION
1. MEDICARE (Medicare#)	MEDICAID (Medicaid#)	TRICARE (ID#/DoD#)	CHAMPVA (Member ID#)	GROUP HEALTH PLAN (ID#)	FECA BLK LUNG (ID#)	OTHER (ID#)	1a. INSURED'S ID NUMBER

2. PATIENT'S NAME (Last Name, First Name, M.I.)		3. PATIENT'S BIRTH DATE	SEX	4. INSURED'S NAME (Last Name, First Name, M.I.)
5. PATIENT'S ADDRESS (No., Street)		6. PATIENT RELATIONSHIP TO INSURED		7. INSURED'S ADDRESS (No., Street)
CITY	STATE	8. RESERVED FOR NUCC USE		CITY	STATE
ZIP CODE	TELEPHONE (Include Area Code)			ZIP CODE	TELEPHONE (Include Area Code)
9. OTHER INSURED'S NAME (Last Name, First Name, M.I.)		10. IS PATIENT'S CONDITION RELATED TO: a. EMPLOYMENT? (Current or Previous) b. AUTO ACCIDENT? PLACE (state) c. OTHER ACCIDENT?		11. INSURED'S POLICY GROUP OR FECA NUMBER
a. OTHER INSURED'S POLICY OR GROUP NUMBER				a. INSURED'S BIRTH DATE	SEX
b. RESERVED FOR NUCC USE				b. OTHER CLAIM ID (Designated by NUCC)
c. RESERVED FOR NUCC USE				c. INSURANCE PLAN NAME OR PROGRAM NAME
d. INSURANCE PLAN NAME OR PROGRAM NAME		10d. CLAIM CODES (Designated by NUCC)		d. IS THERE ANOTHER HEALTH BENEFIT PLAN? If yes, complete items 9, 9a, and 9d
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM 12. 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

PHYSICIAN OR SUPPLIER INFORMATION
14. DATE OF CURRENT ILLNESS, INJURY, OR PREGNANCY (LMP) QUAL.	15. OTHER DATE QUAL.	16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE	17a.	18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE	17b.
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)		20. OUTSIDE LAB?	$ CHARGES
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) A. B. C. D. E. F. G. H. I. J. K. L.		22. RESUBMISSION CODE	ORIGINAL REF. NO.
		23. PRIOR AUTHORIZATION NUMBER

24. A. DATE(S) OF SERVICE		B. PLACE OF SERVICE	C. EMG	D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances)		E. DIAGNOSIS POINTER	F. $ CHARGES	G. DAYS OR UNITS	H. EPSDT Family Plan	I. ID. QUAL.	J. RENDERING PROVIDER ID. #
FROM	TO	B. PLACE OF SERVICE	C. EMG	CPT/HCPCS	MODIFIER	E. DIAGNOSIS POINTER	F. $ CHARGES	G. DAYS OR UNITS	H. EPSDT Family Plan	I. ID. QUAL.	J. RENDERING PROVIDER ID. #
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25. FEDERAL TAX I.D. NUMBER	SSN/EIN	26. PATIENT'S ACCOUNT NO.	27. ACCEPT ASSIGNMENT?	28. TOTAL CHARGE	29. AMOUNT PAID	30. Reserved for NUCC Use
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) SIGNED DATE		32. SERVICE FACILITY LOCATION INFORMATION		33. BILLING PROVIDER INFORMATION AND PHONE NUMBER
		a.	b.	a.	b.

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