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Copy Of Cms1500 Formexcel(2) Unit 2(2) Team Work(1) Helena

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medical coding and billing

medical coding and billing

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    Copy Of Cms1500 Formexcel(2) Unit 2(2) Team Work(1) Helena Copy Of Cms1500 Formexcel(2) Unit 2(2) Team Work(1) Helena Document Transcript

    • PLEASE DO NOT STAPLE IN THIS AREA PICA 1. MEDICARE MEDICAID CHAMPUS CHAMPVA (Medicare#) x (Medicaid#) (Sponsor's SSN) FECA BLK LUNG OTHER (SSN) (ID) 3. PATIENT'S BIRTH DATE 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) MM DD Vernon Vaugn 11 9 5. PATIENT'S ADDRESS (No. Street) 6. PATIENT'S RELATIONSHIP TO INSU 1234 Victory Blvd SELF SPOUSE x CITY STATE 8. PATIENT'S STATUS Valley Vista VT SINGLE ZIP CODE MARRIED x TELEPHONE (Include Area Code) 5777 802-555-0577 OTHER 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) IS PATIENT'S CONDITION RELATE 10. a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PR YES b. OTHER INSURED'S DOB SEX b. AUTO ACCIDENT? MM DD YY M F YES c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? YES d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE Medicare 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE - I authorize the release of any medical or othe necessary to process this claim. I also request payment of government benefits either to myself or to the assignment below. SIGNED:X 14. DATE OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR S MM DD YY INJURY (Accident) OR GIVE FIRST DATE Pregnancy (LMP) 17. NAME OF REFERRING PHYSICIAN OR OTHER 17a. I.D. NUMBER OF REFERRING PH SOURCE F15982 Vera Vega 19. RESERVED FOR LOCAL USE 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE 1, 2, 3, OR 4 TO ITEM 24E BY LINE) 1. Cancer of Prostate . 3.
    • 2. . 4. 24. A B C D DATE(S) OF SERVICE PLACE TYPE PROCEDURES, SER FROM TO OF OF SUPPLIES (Explain U MM / DD / YY MM / DD / YY SERVICE SERVICE CPT/HCPCS 1. office 06/26/2009 6/26/2009 2. 06/26/2009 6/28/2009 office 3. office 06/26/2009 6/28/2009 4. 06/26/2008 6/28/2009 office 5. 06/26/2008 6/28/2009 office 6. 06/26/2008 6/28/2009 office 25. FEDERAL TAX I.D. NUMBER 26. PATIENT'S ACCOUNT NO. 55-4052798 SSN EIN X x 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. NAME AND ADDRESS OF FACILIT INCLUDING DEGREES OR CREDENTIALS WERE RENDERED (If other than h X SIGNED: X DATE: X (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) 586625 3-02
    • CIGNA HealthCare MAIL COMPLETED CLAIM ADDRESS SHOWN ON Y HEALTH INSURANCE CLAIM FORM PICA AMPVA GROUP HEALTH PLAN 1A. INSURED'S ID NUMBER (VA File#) (SSN or ID) 777-77-0000A/77-0000 ABC DATE SEX 4. INSURED NAME (Last Name, First Name, Middle Initial) YY M F 1971 x Vernon Vaughn TIONSHIP TO INSURED 7. INSURED'S ADDRESS (No. Street) CHILD OTHER 1234 Victory Blvd CITY STATE EMPLOYED Valley Vista FULL-TIME STUDENT ZIP CODE TELEPHONE (Include Area Code) PART-TIME STUDENT 5777 (802)555-0577 NDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER 36928 CURRENT OR PREVIOUS) a. OTHER INSURED'S DOB SEX NO x MM DD YY M PLACE (ST) NO x b. EMPLOYER'S NAME OR SCHOOL NAME X c. INSURANCE PLAN NAME OR PROGRAM NAME NO x Medicare/ Winter Innsurance Company R LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES x NO If yes, return to and complete item 9 a-d ny medical or other information 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE to myself or to the party who accepts payment of medical benefits to the undersigned physician or described below. DATE: X post date here SIGNED: X HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCC MM DD YY MM DD YY MM FROM TO F REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SER MM DD YY MM FROM TO 20. OUSIDE LAB? $ CHARGES YES NO M 24E BY LINE) 22. MEDICAID RESUBMISSION V CODE ORIGINAL REF. NO. .
    • . 23. PRIOR AUTHORIZATION NUMBER D E F G H I J OCEDURES, SERVICES, OR DIAGNOSIS DAYS EPSDT PPLIES (Explain Unusual Circumstnc) $ CHARGES OR Family EMG COB MODIFIER CODE UNIT Plan 100 35 20 25 20 35 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALAN YES NO 235 X X $ $ RESS OF FACILITY WHERE SERVICE 33. PHYSICIAN'S, SUPPLIERS BILLING NAME, ADDRESS, ZI D (If other than home or office) X PIN # X GRP# PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM HCFA-1500 (12-90), FORM APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED
    • lthCare LETED CLAIM FORM TO THE HOWN ON YOUR ID CARD. le Initial) VT F ompany to and 9 a-d IGNATURE - I authorize d physician or supplier for services RRENT OCCUPATION DD YY URRENT SERVICES DD YY EF. NO.
    • K RESERVED FOR LOCAL USE 30. BALANCE DUE 235 ADDRESS, ZIP CODE & PHONE # (12-90), FORM RRB-1500 , APPROVED OMB-0720-0001 (CHAMPUS)