Nucc Form Cms 1500 – Fill Out and Use This PDF

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

PICA

PICA

1. MEDICARE

MEDICAID

TRICARE

CHAMPVA

GROUP

FECA

OTHER

1a. INSURED’S I.D. NUMBER

(For Program in Item 1)

CHAMPUS

HEALTH PLAN

BLK LUNG

(Medicare #)

(Medicaid

#)

(Sponsor’s SSN)

(Member ID#)

(SSN or ID)

(SSN)

(ID)

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

3. PATIENT’S BIRTH DATE

SEX

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

MM

DD

YY

M

F

5. PATIENT’S ADDRESS (No., Street)

6. PATIENT RELATIONSHIP TO INSURED

7. INSURED’S ADDRESS (No., Street)

Self

Spouse

Child

Other

CITY

STATE

8. PATIENT STATUS

CITY

STATE

Single

Married

Other

ZIP CODE

TELEPHONE (Include Area Code)

ZIP CODE

TELEPHONE (Include Area Code)

(

)

Employed

Full-Time

Part-Time

(

)

Student

Student

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

10. IS PATIENT’S CONDITION RELATED TO:

11. INSURED’S POLICY GROUP OR FECA NUMBER

a. EMPLOYMENT? (Current or Previous)

a. OTHER INSURED’S POLICY OR GROUP NUMBER

a. INSURED’S DATE OF BIRTH

SEX

YES

NO

MM

DD

YY

M

F

b. OTHER INSURED’S DATE OF BIRTH

SEX

b. AUTO ACCIDENT?

PLACE (State)

b. EMPLOYER’S NAME OR SCHOOL NAME

MM

DD

YY

M

F

YES

NO

c. EMPLOYER’S NAME OR SCHOOL NAME

c. OTHER ACCIDENT?

c. INSURANCE PLAN NAME OR PROGRAM NAME

YES

NO

d. INSURANCE PLAN NAME OR PROGRAM NAME

10d. RESERVED FOR LOCAL USE

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

YES

NO

If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize

12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary

payment of medical benefits to the undersigned physician or supplier for

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

services described below.

below.

SIGNED

DATE

SIGNED