Form Health Claim – Fill Out and Use This PDF

The Health Insurance Claim Form, approved by the National Uniform Claim Committee and identifiable by the OMB No. 1240-0044, plays a crucial role in the healthcare billing process. It is designed for patients to request reimbursement or direct payment for medical services from their insurance carriers. With an expiration date set for June 30, 2024, this form ensures that both providers and patients adhere to a standardized method of claim submission, thus facilitating timely and accurate processing of health insurance claims. To ease the process of securing the benefits entitled to you, begin by filling out the Health Claim form available via the button below.

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Form Health Claim PDF Details

The Health Insurance Claim Form, approved by the National Uniform Claim Committee and adhering to the OMB No. 1240-0044 with an expiration date of 06/30/2024, serves as a critical bridge between medical service providers and insurance payers, including Medicare, Medicaid, TRICARE, CHAMPVA, group health initiatives, and others. This comprehensive document facilitates the billing process for medical services under various federal programs like the Federal Employees' Compensation Act (FECA), the Black Lung Benefits Act (BLBA), and the Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA), emphasizing its utility in the transparent and efficient handling of health claims. Key sections of the form capture patient identification, insurance details, diagnosis codes, service dates, and charges, ensuring that all necessary data for claim processing is systematically captured. The form also underscores the importance of patient and provider signatures to authorize the release of medical information and the direct payment of medical benefits, signifying necessary consent that aligns with legal and procedural requisites. With detailed instructions for completion provided by the Office of Workers' Compensation Programs (OWCP), the form is tailored to meet the specific needs of claimants across diverse health programs, emphasizing the government's commitment to facilitating access to medical benefits while maintaining stringent standards for documentation and privacy as outlined by the Paperwork Reduction Act of 1995.

Question	Answer
Form Name	Form Health Claim
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	form owcp 1500, form health claim, form insurance claim, form insurance claim print

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HEALTH INSURANCE CLAIM FORM

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE

OMB No. 1240-0044

Expires: 06/30/2024

1.	MEDICARE	MEDICAID	TRICARE	CHAMPVA	GROUP HEALTH	FECA BLK	OTHER	1a. INSURED I.D. NUMBER	(For Program in Item 1)


	(Medicare#)	(Medicaid#)	(ID#/DoD#)	(Member ID#)	PLAN (ID#)	LUNG (ID#)	(ID#)

2. PATIENT'S NAME (Last, First, Middle Initial)

3. PATIENT'S BIRTH DATE

SEX

4. INSURED'S NAME (Last, First, Middle Initial)

INSURED

5. PATIENT'S ADDRESS (Street,

City, State, Zip)

6. PATIENT RELATIONSHIP TO

7. INSURED'S ADDRESS (Street, City, State, Zip)

Self

Spouse

Child

Other

8. RESERVED FOR NUCC USE

TELEPHONE (Include Area Code):

9. OTHER INSURED'S NAME (Last, First, Middle Initial)

10. PATIENT'S CONDITION RELATED TO:

11. INSURED'S POLICY GROUP OR FECA NUMBER

a. EMPLOYMENT? (Current or Previous)

a. INSURED'S DATE OF BIRTH

SEX

a. OTHER INSURED POLICY OR GROUP NUMBER

Yes

b. AUTO ACCIDENT?

PLACE (State)

by NUCC)

b. RESERVED FOR NUCC USE

b. OTHER CLAIM ID (Designated

Yes

c. RESERVED FOR NUCC USE

c. OTHER ACCIDENT?

c. INSURANCE PLAN NAME OR PROGRAM NAME

Yes

d. PATIENT'S PLAN OR PROGRAM NAME

10d. CLAIM CODES (Designated by NUCC)

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

Yes

If yes, complete items 9, 9a, and 9d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.

13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE

12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary to I authorize payment of medical benefits to the undersigned physician

process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.

or supplier for services described below..

SIGNED _________________________________________________

DATE

SIGNED _______________________________________________

14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP)

15. OTHER DATE

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

QUAL.

FROM:

TO:

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

17a.

18. HOSPITALIZATION DATES

TO CURRENT SERVICES

19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)

17b.

NPI

FROM:

TO:

20. OUTSIDE LAB?

$ CHARGES

Yes

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24e)

22. RESUBMISSION CODE

ICD Ind.

ORIGINAL REF. NO.

23. PRIOR AUTHORIZATION NUMBER

24. A. DATE(S) OF SERVICE

D. PROCEDURES, SERVICES, OR SUPPLIES

PLACE OF

(Explain Unusual Circumstances)

DIAGNOSIS

DAYS OR

EPSOT

RENDERING

From

SERVICE

EMG

CPT/HCPSCS

MODIFIER

POINTER (A-L)

$ CHARGES

UNITS

Family

QUAL.

PROVIDER NPI #

Plan

NPI

25. FEDERAL TAX I.D. NUMBER

26.

PATIENT'S ACCOUNT

NO.

27. ACCEPT

ASSIGNMENT?

28. TOTAL CHARGE

29. AMOUNT PAID

30. Rsvd for NUCC Use

SSN EIN

(For govt. claims, see back)

Yes

31. SIGNATURE OF PHYSICIAN OR SUPPLIER

32. SERVICE FACILITY LOCATION

INFORMATION

33. BILLING PROVIDER INFO & PH #

INCLUDING DEGREES OR CREDENTIALS

(I certify that the statements on the reverse

apply to this bill and are made a part thereof.)

SIGNED __________________

DATE

PATIENT AND INSURED INFORMATION

PHYSICIAN OR SUPPLIER INFORMATION

NUCC instruction Manual available at www.nucc.org

PLEASE PRINT OR TYPE

APPROVED OMB-093B-1197 FORM CMS-1500 (06-15)

How to Edit Form Health Claim Online for Free

Filling out how to form insurance claim fill out is a snap. Our experts designed our tool to really make it intuitive and allow you to fill out any PDF online. Below are a few steps that you should stick to:

Step 1: Choose the "Get Form Now" button to get started on.

Step 2: So, you're on the file editing page. You may add information, edit present data, highlight specific words or phrases, insert crosses or checks, add images, sign the form, erase unwanted fields, etc.

These segments will help make up the PDF form:

Within the field b RESERVED FOR NUCC USE, b AUTO ACCIDENT, PLACE State, b OTHER CLAIM ID Designated by NUCC, c RESERVED FOR NUCC USE, Yes, c OTHER ACCIDENT, Yes, c INSURANCE PLAN NAME OR PROGRAM, d PATIENTS PLAN OR PROGRAM NAME, d CLAIM CODES Designated by NUCC, d IS THERE ANOTHER HEALTH BENEFIT, Yes, If yes complete items a and d, and READ BACK OF FORM BEFORE type in the data which the program requires you to do.

Entering details in form insurance claim stage 2

Put in writing any details you need inside the area NPI, NPI, FEDERAL TAX ID NUMBER, PATIENTS ACCOUNT NO, SSN, EIN, ACCEPT ASSIGNMENT For govt claims, TOTAL CHARGE, AMOUNT PAID, Rsvd for NUCC Use, SIGNATURE OF PHYSICIAN OR, SIGNED DATE, SERVICE FACILITY LOCATION, BILLING PROVIDER INFO PH, and Yes.

stage 3 to finishing form insurance claim

Step 3: Click the "Done" button. Next, you may transfer your PDF document - download it to your device or send it by means of email.

Step 4: Make at least a couple of copies of your file to refrain from different upcoming challenges.

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