This document appears to be a health insurance claim form containing patient and insurance information. It includes fields for the patient and insured's names, addresses, dates of birth, policy and identification numbers. There are also sections to provide diagnosis codes, procedure codes, dates of service, charges and payments. The form is signed by both the patient and the treating physician to authorize the release of medical information and payment of benefits.
Providing Post-Adoption Services for Providence PlaceJudith Bell
Providence Place provide post adoption services like medical transportation assistance, medical history information, and responding in an emergency. We want adoptive parents to know their children’s medical history to keep them healthy and safe.
LA County HIV Public Health Fellowship Program Application FormEric Olander
To apply for the Los Angeles County HIV Public Health Services Fellowship Program, interested candidates must submit a letter of interest – including career goals and how the fellowship would help him/her achieve those goals – their curriculum vitae, and a list of references, to:
County of Los Angeles Department of Health Services
Los Angeles County HIV Public Health Fellowship Program
5850 South Main Street, Room 2214
Los Angeles, California, 90003
Providing Post-Adoption Services for Providence PlaceJudith Bell
Providence Place provide post adoption services like medical transportation assistance, medical history information, and responding in an emergency. We want adoptive parents to know their children’s medical history to keep them healthy and safe.
LA County HIV Public Health Fellowship Program Application FormEric Olander
To apply for the Los Angeles County HIV Public Health Services Fellowship Program, interested candidates must submit a letter of interest – including career goals and how the fellowship would help him/her achieve those goals – their curriculum vitae, and a list of references, to:
County of Los Angeles Department of Health Services
Los Angeles County HIV Public Health Fellowship Program
5850 South Main Street, Room 2214
Los Angeles, California, 90003
Pre- Authorization form is to be filled in case of hospitalization. It is basically a declaration by the patient to make claim for the expenses incurred during the hospitalization. Easy Health Pre- Authorization form will seek information about the patient or the insured person like name of the patient, contact details, age, policy number and card ID number, name of the hospital, nature of illness and other related details. All columns must be closely examined to provide genuine information to the insurer. The form must be duly filled and then must be attached with all the necessary documents to avail the service.
Pre- Authorization form is to be filled in case of hospitalization. It is basically a declaration by the patient to make claim for the expenses incurred during the hospitalization. While seeking health insurance coverage under Optima Restore, the Pre- Authorization form must be filled to avail the policy support. Through this Apollo Munich seek information about the patient or the insured person like name of the patient, contact details, age, policy number and card ID number, name of the hospital, nature of illness and other related details. All columns must be closely examined to provide genuine information to the insurer. The form must be duly filled and then must be attached with all the necessary documents absence of which can lead to complication.
Life insurance is a contract between you and the life insurance company (the insurer), which provides you (the assured) or your beneficiary for whose benefit the policy is taken with a pre-determined amount on the happening of a particular event contingent on the duration of human life
Health plus claim intimation form is for Health Insurance Policies (HCB & MSB Claims).Form must be completed & signed by Policy Holder / Principal Insured only and submitted to the TPA.
Pre- Authorization form is to be filled in case of hospitalization. It is basically a declaration by the patient to make claim for the expenses incurred during the hospitalization. While seeking health insurance coverage under Optima Plus, the Pre- Authorization form must be filled to avail the policy support. Through this Apollo Munich seek information about the patient or the insured person like name of the patient, contact details, age, policy number and card ID number, name of the hospital, nature of illness and other related details. All columns must be closely examined to provide genuine information to the insurer. The form must be duly filled and attached with all the necessary documents absence of which can lead to complication.
http1500cms.comBECAUSE THIS FORM IS USED BY VARIOUS .docxpooleavelina
http://1500cms.com/
BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BY
APPLICABLE PROGRAMS.
NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may
be guilty of a criminal act punishable under law and may be subject to civil penalties.
REFERS TO GOVERNMENT PROGRAMS ONLY
MEDICARE AND CHAMPUS PAYMENTS: A patient’s signature requests that payment be made and authorizes release of any information necessary to process
the claim and certifies that the information provided in Blocks 1 through 12 is true, accurate and complete. In the case of a Medicare claim, the patient’s signature
authorizes any entity to release to Medicare medical and nonmedical information, including employment status, and whether the person has employer group health
insurance, liability, no-fault, worker’s compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made. See 42
CFR 411.24(a). If item 9 is completed, the patient’s signature authorizes release of the information to the health plan or agency shown. In Medicare assigned or
CHAMPUS participation cases, the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary as the full charge,
and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge
determination of the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submitted. CHAMPUS is not a health insurance program but
makes payment for health benefits provided through certain affiliations with the Uniformed Services. Information on the patient’s sponsor should be provided in those
items captioned in “Insured”; i.e., items 1a, 4, 6, 7, 9, and 11.
BLACK LUNG AND FECA CLAIMS
The provider agrees to accept the amount paid by the Government as payment in full. See Black Lung and FECA instructions regarding required procedure and
diagnosis coding systems.
SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE, CHAMPUS, FECA AND BLACK LUNG)
I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me or were furnished
incident to my professional service by my employee under my immediate personal supervision, except as otherwise expressly permitted by Medicare or CHAMPUS
regulations.
For services to be considered as “incident” to a physician’s professional service, 1) they must be rendered under the physician’s immediate personal supervision
by his/her employee, 2) they must be an integral, although incidental part of a covered physician’s service, 3) they must be of kinds commonly furnished in physician’s
offices, and 4) the services of nonphysicians must be included on the physician’s bills.
For CHA ...
Situations 1 and 2 Making Decisions About InterventionsSitua.docxjennifer822
Situations 1 and 2: Making Decisions About Interventions*
Situation 1
Think back to a client (individual, family, group, agency, or community) with whom you have worked. Place a check mark next to each criterion you used to make your practice decision. If you have not yet worked with a client, think of the criteria on which you would probably rely.
____1. Your intuition (gut feeling) about what will be effective
____2. What you have heard from other professionals in informal exchanges
____3. Your experience with a few cases
____4. Your demonstrated track record of success based on data you have gathered systematically and regularly
____5. What fits your personal style
____6. What was usually offered at your agency
____7. Self-reports of other clients about what was helpful
____8. Results of controlled experimental studies (data that show a method is helpful)
____9. What you are most familiar with
____10. What you know by critically reading professional literature
Situation 2
Imagine you have a potentially serious medical problem and you seek help from a physician to examine treatment options. Place a check mark next to each criterion you would like your physician to rely on when he or she makes recommendations about your treatment.
____1. The physician’s intuition (gut feeling) that a method will work
____2. What he or she has heard from other physicians in informal exchanges
____3. The physician’s experience with a few cases
____4. The physician’s demonstrated track record of success based on data he or she has gathered systematically and regularly
____5. What fits his or her personal style
____6. What is usually offered at the clinic
____7. Self-reports of patients about what was helpful
____8. Results of controlled experimental studies (data that show a method is helpful)
____9. What the physician is most familiar with
____10. What the physician has learned by critically reading professional literature
*From Gambrill, E., & Gibbs, L. (2017). Making decisions about intervention. In Criticalthinking for helping professionals: A skills-based workbook (4th ed., pp. 69–70). New York, NY: Oxford University Press.
Module 03
Course Project - Part 1
PATIENT REGISTRATION FORM
Practice – The People’s Clinic
Address – 1000 Town Square, Anytown Pennsylvania 54321
Phone – 555-741-8529
PATIENT INFORMATION
Patient – Mrs. Jane Doe
Married
Former name – Jane Smith
DOB – 01/01/1960
SSN - 123-45-6789
Address – 123 Main Street, Anytown Pennsylvania 54321
Phone – 555-987-6543
Occupation – Nurse
Employer – The People’s Hospital
Employer Phone – 555-456-7890
Doctor referral to clinic
INSURANCE INFORMATION
Jane Doe is responsible for payment
Primary insurance is Blue Cross Blue Shield
Subscriber – Jane Doe
ID – 123123123
Grp – 00550055
No secondary insurance
IN CASE OF EMERGENCY
Suzie Smith (sister)
Home – 555-567-8910
Work – 555-678-9012
.
Situations 1 and 2 Making Decisions About InterventionsSitua.docxedgar6wallace88877
Situations 1 and 2: Making Decisions About Interventions*
Situation 1
Think back to a client (individual, family, group, agency, or community) with whom you have worked. Place a check mark next to each criterion you used to make your practice decision. If you have not yet worked with a client, think of the criteria on which you would probably rely.
____1. Your intuition (gut feeling) about what will be effective
____2. What you have heard from other professionals in informal exchanges
____3. Your experience with a few cases
____4. Your demonstrated track record of success based on data you have gathered systematically and regularly
____5. What fits your personal style
____6. What was usually offered at your agency
____7. Self-reports of other clients about what was helpful
____8. Results of controlled experimental studies (data that show a method is helpful)
____9. What you are most familiar with
____10. What you know by critically reading professional literature
Situation 2
Imagine you have a potentially serious medical problem and you seek help from a physician to examine treatment options. Place a check mark next to each criterion you would like your physician to rely on when he or she makes recommendations about your treatment.
____1. The physician’s intuition (gut feeling) that a method will work
____2. What he or she has heard from other physicians in informal exchanges
____3. The physician’s experience with a few cases
____4. The physician’s demonstrated track record of success based on data he or she has gathered systematically and regularly
____5. What fits his or her personal style
____6. What is usually offered at the clinic
____7. Self-reports of patients about what was helpful
____8. Results of controlled experimental studies (data that show a method is helpful)
____9. What the physician is most familiar with
____10. What the physician has learned by critically reading professional literature
*From Gambrill, E., & Gibbs, L. (2017). Making decisions about intervention. In Criticalthinking for helping professionals: A skills-based workbook (4th ed., pp. 69–70). New York, NY: Oxford University Press.
Module 03
Course Project - Part 1
PATIENT REGISTRATION FORM
Practice – The People’s Clinic
Address – 1000 Town Square, Anytown Pennsylvania 54321
Phone – 555-741-8529
PATIENT INFORMATION
Patient – Mrs. Jane Doe
Married
Former name – Jane Smith
DOB – 01/01/1960
SSN - 123-45-6789
Address – 123 Main Street, Anytown Pennsylvania 54321
Phone – 555-987-6543
Occupation – Nurse
Employer – The People’s Hospital
Employer Phone – 555-456-7890
Doctor referral to clinic
INSURANCE INFORMATION
Jane Doe is responsible for payment
Primary insurance is Blue Cross Blue Shield
Subscriber – Jane Doe
ID – 123123123
Grp – 00550055
No secondary insurance
IN CASE OF EMERGENCY
Suzie Smith (sister)
Home – 555-567-8910
Work – 555-678-9012
.
Health plus claim is a part of life insurance. Issuance of this form does not amount to admission of any liability under the claim on the part of the insurers.
1. Part II • Blank Forms 557
1a. INSURED’S I.D. NUMBER
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
7. INSURED’S ADDRESS (No., Street)
CITY
11. INSURED’S POLICY GROUP OR FECA NUMBER
a. INSURED’S DATE OF BIRTH
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize
payment of medical benefits to the undersigned physician or
supplier for services described below.
F
HEALTH INSURANCE CLAIM FORM
OTHER1.
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
ILLNESS (First symptom) OR
INJURY (Accident) OR
PREGNANCY(LMP)
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
GIVE FIRST DATE
14. DATE OF CURRENT:
19. RESERVED FOR LOCAL USE
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)
From
MM DD YY MM DD YY
To
1
2
3
4
6
25. FEDERAL TAX I.D. NUMBER 27. ACCEPT ASSIGNMENT?
(For govt. claims, see back)
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.)
DATESIGNED
SIGNED
ORIGINAL REF. NO.
$ CHARGES
28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
$$$
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
5. PATIENT’S ADDRESS (No., Street)
ZIP CODE TELEPHONE (Include Area Code)
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
a. OTHER INSURED’S POLICY OR GROUP NUMBER
b. OTHER INSURED’S DATE OF BIRTH
c. EMPLOYER’S NAME OR SCHOOL NAME
d. INSURANCE PLAN NAME OR PROGRAM NAME
YES NO
( )
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
22. MEDICAID RESUBMISSION
CODE
23. PRIOR AUTHORIZATION NUMBER
MM DD YY
YES NO
1.
2.
DATE(S) OF SERVICE D. PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS MODIFIER
DIAGNOSIS
POINTER
FM
SEX
MM DD YY
YES NO
YES NO
YES NO
PLACE (State)
GROUP
HEALTH PLAN
FECA
BLK LUNG
Single
3. PATIENT’S BIRTH DATE
6. PATIENT RELATIONSHIP TO INSURED
8. PATIENT STATUS
10. IS PATIENT’S CONDITION RELATED TO:
a. EMPLOYMENT? (Current or Previous)
b. AUTO ACCIDENT?
c. OTHER ACCIDENT?
10d. RESERVED FOR LOCAL USE
Employed
Other
M
SEX
DAYS OR
UNITS
F.E.
Self Spouse Child Other
YES NO
PROVIDER ID. #
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.
RENDERING
32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #
NUCC Instruction Manual available at: www.nucc.org
c. INSURANCE PLAN NAME OR PROGRAM NAME
Full-Time
Student
Part-Time
Student
.b..a.b..a
NPI
NPI
NPI
NPI
NPI
NPI
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
G. H. I. J.
ID.
QUAL.
NPI NPI
( )
APPROVED OMB-0938-0999 FORM CMS-1500 (08-05)
1500
STATE
SEX
MM DD YY
b. EMPLOYER’S NAME OR SCHOOL NAME
If yes,
MM DD YY
5
M F
3.
4.
( )
C.
EMG
17b. NPI
MEDICARE MEDICAID TRICARE
CHAMPUS
CHAMPVA
(Sponsor’s SSN)(Medicaid #)(Medicare #) (Member ID#)
(For Program in Item 1)
CARRIER
TELEPHONE (Include Area CodeZIP CODE
$ CHARGES20. OUTSIDE LAB?
PHYSICIANORSUPPLIERINFORMATION
CITY STATE
24. A. B.
PLACE OF
SERVICE
EPSDT
Family
Plan
(SSN or ID) (SSN) (ID)
PATIENTANDINSUREDINFORMATION
Married
26. PATIENT’S ACCOUNT NO.EINSSN
TOFROM
TOFROM
MM DD YY MM DD YYMM DD YY
MM DD YY MM DD YY
return to and complete item 9 a-d.
PICA PICA
Form 84
D4477.indb 557D4477.indb 557 11/15/07 3:24:15 PM11/15/07 3:24:15 PM
467980123
PATIENT, MARY, S 10 10 59 A1 GROCERY
91 HOME STREET 1 MAIN ST
NOWHERE NY
12367-1234 101 2018989
NOWHERE NY
12367 101 5554561
MSP9761
A1 GROCERY
STATE INSURANCE FUND
0120 01 21
728 85
721 90
E849 3
01 27 11 99212 45 00 1
01 27 11 20552 75 00 1
111234523 17-2 120 00
KANDA J MYRVIK
101 1111234
ERIN A HELPER MD
101 MEDIC DRIVE
ANYWHERE, NY 12345
123567890