Defraud Details

The Bellevue Medical Claim Form is a document that provides insurance companies or other third-party payers with information on the diagnosis, treatment and services provided to an individual. The form is completed by a provider who has examined a patient and can be submitted electronically through the use of EDI (Electronic Data Interchange). It must include the date of service, medical claim number, name of insured, diagnosis codes from ICD-10 CM (International Classification for Diseases) 9th edition codes. A Bellevue Medical Claim Form can be used as evidence in court cases where malpractice occurs. These forms are also necessary when submitting claims for reimbursement from health insurance carriers such as Medicaid or Medicare.

You'll find it beneficial to know how much time you will need to prepare this bellevue medical claim form and how long the form is.

QuestionAnswer
Form NameBellevue Medical Claim Form
Form Length1 pages
Fillable?Yes
Fillable fields48
Avg. time to fill out9 min 55 sec
Other nameshma insurance claims address, MEDICARE, FALSE, Administrators

Form Preview Example

CITY OF RENTON

Send claims to: Healthcare Management Administrators, Inc.

P.O. Box 85008, Bellevue, WA 98015

 

 

Toll Free (800) 869-7093 Local (425) 462-1000

 

MEDICAL CLAIM FORM

 

 

PART 1: Employee Information

 

EMPLOYEE NAME (Last and First)

EMPLOYEE DATE OF BIRTH MONTH DAY YEAR

EMPLOYEE SOCIAL SECURITY #

GROUP #

4034

EMPLOYEE ADDRESS

CITY

STATE

ZIP

IS THIS AN ADDRESS CHANGE?

YES NO

EMPLOYEE'S TELEPHONE NUMBER

 

 

SINGLE

 

 

MARRIED

 

 

 

 

 

 

WIDOWED

 

 

LEGALLY SEPARATED

 

 

 

DIVORCED

 

NAME OF SPOUSE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF DIVORCED & CLAIM IS FOR DEPENDENT CHILD, ANSWER THE FOLLOWING QUESTIONS: A) IS THIS CHILD IN YOUR PERMANENT CUSTODY?

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B) IS THERE A COURT ORDER FOR PROVISION OF MEDICAL CARE FOR THIS CHILD?

 

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART 2: Patient Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT NAME

 

 

 

 

IS PATIENT

 

 

 

EMPLOYEE

 

 

SPOUSE

 

CHILD

 

 

 

 

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MARITAL STATUS

 

 

 

 

IF OTHER, SPECIFY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT DATE OF BIRTH

IF CLAIM IS FOR DEPENDENT OVER AGE 19, IS THE DEPENDENT A FULL TIME STUDENT?

 

 

 

 

 

 

 

 

 

 

MONTH DAY YEAR

IF SO, PLEASE PROVIDE PROOF OF STUDENT STATUS.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART 3: Description of Claim

DESCRIBE ILLNESS OR INJURY:

WORK RELATED ILLNESS OR INJURY:

YES

 

NO

IF YES, DID YOU OR WILL YOU BE FILING A CLAIM WITH L&I?

YES NO

IF CLAIM IS DUE TO ACCIDENT STATE WHEN, WHERE AND HOW THE ACCIDENT OCCURRED:

HAS PATIENT BEEN TREATED FOR THIS ILLNESS OR INJURY WITHIN THE PAST 12 MONTHS?

IF YES, NAME AND ADDRESS OF ATTENDING PHYSICIAN

YES

NO IF YES, DATE OF SERVICE:

REFERRING PHYSICIAN IF APPLICABLE

PART 4: Other Group Health Insurance

ARE YOU OR ANY OF YOUR FAMILY MEMBERS COVERED BY OTHER INSURANCE FOR

 

MEDICAL, DENTAL, OR VISION BENEFITS?

 

 

YES

 

 

NO

CHECK ONLY THOSE COVERED BY OTHER GROUP INSURANCE:

 

 

 

 

 

 

SELF

 

SPOUSE DATE OF BIRTH

 

 

 

 

 

 

DEPENDENT(S)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIST THE DEPS.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND ADDRESS OF OTHER INSURANCE CARRIER:

POLICY NUMBER:

EFFECTIVE DATE:

IS PATIENT ELIGIBLE FOR MEDICARE BENEFITS?

 

YES

NO

IF YES, ENTER DATE OF ELIGIBILITY

SOCIAL SECURITY NO.

PART 5: Complete for all

I HEREBY CERTIFY THAT THE ABOVE STATEMENTS ARE COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY, FILES A STATEMENT OF CLAIM CONTAINING FALSE INCOMPLETE OR MISLEADING INFORMATION MAY BE GUILTY OF A CRIMINAL ACT PUNISHABLE UNDER LAW.

EMPLOYEE SIGNATURE

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART 6: Claims Benefit Assignment and Authorization

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNED (BY EMPLOYEE)

 

 

 

I AUTHORIZE PAYMENT OR BENEFITS DIRECTLY TO THE PHYSICIAN OR SUPPLIER:

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTHORIZATION TO RELEASE INFORMATION: I expressly authorize any provider of care to

 

SIGNED (BY PATIENT, OR PARENT, IF MINOR)

 

 

 

furnish HMA, any records concerning me or any Member of my family for whom benefits or services

 

 

 

 

 

 

 

 

 

 

has been claimed.

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How to Edit Bellevue Medical Claim Form

Creating the po box 85008 bellevue wa 98015 form is not hard with this PDF editor. Keep up with the next actions to get the document ready in no time.

Step 1: Choose the "Get Form Here" button.

Step 2: So, you are on the form editing page. You may add content, edit current data, highlight certain words or phrases, put crosses or checks, add images, sign the form, erase unneeded fields, etc.

The PDF file you are going to create will cover the following areas:

MEDICARE fields to fill out

Include the demanded particulars in the YES, IF YES, YES, IF CLAIM IS DUE TO ACCIDENT STATE, HAS PATIENT BEEN TREATED FOR THIS, IF YES, YES, IF YES, REFERRING PHYSICIAN IF APPLICABLE, NAME AND ADDRESS OF OTHER, MEDICAL, YES, CHECK ONLY THOSE COVERED BY OTHER, SELF, SPOUSE, LIST THE DEPS, DATE OF BIRTH, DEPENDENT(S), POLICY NUMBER:, EFFECTIVE DATE:, IS PATIENT ELIGIBLE FOR MEDICARE, YES, IF YES, SOCIAL SECURITY NO, and PART 5: Complete for all I HEREBY part.

MEDICARE YES, IF YES, YES, IF CLAIM IS DUE TO ACCIDENT STATE, HAS PATIENT BEEN TREATED FOR THIS, IF YES, YES, IF YES, REFERRING PHYSICIAN IF APPLICABLE, NAME AND ADDRESS OF OTHER, MEDICAL, YES, CHECK ONLY THOSE COVERED BY OTHER, SELF, SPOUSE, LIST THE DEPS, DATE OF BIRTH, DEPENDENT(S), POLICY NUMBER:, EFFECTIVE DATE:, IS PATIENT ELIGIBLE FOR MEDICARE, YES, IF YES, SOCIAL SECURITY NO, and PART 5: Complete for all I HEREBY fields to insert

It is vital to write down specific information within the area EMPLOYEE SIGNATURE, PART 6: Claims Benefit Assignment, DATE, SIGNED (BY EMPLOYEE), I AUTHORIZE PAYMENT OR BENEFITS, SIGNED (BY PATIENT, DATE, and DATE.

part 3 to finishing MEDICARE

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