Samba Insurance Claim Form – Fill Out and Use

1. MEDICARE

MEDICAID

CHAMPUS

CHAMPVA

GROUP

FECA

OTHER

1a. INSURED’S I.D. NUMBER

(FOR PROGRAM IN ITEM 1)

HEALTH PLAN

BLK LUNG

(Medicare #)

(Medicaid #)

(Sponsor’s SSN)

(VA File #)

X (SSN or ID)

(SSN)

(ID)

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

3. PATIENT’S BIRTH DATE

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

MM

DD

YY

SEX

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 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. AUTO ACCIDENT?

PLACE (State)

b. OTHER INSURED’S DATE OF BIRTH

SEX

b. EMPLOYER’S NAME

MM

DD

YY

M

F

YES

NO

c. EMPLOYER’S 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

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

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

process this claim.

payment of medical benefits to the undersigned physician or supplier for

services described below.

Signed

Date

Signed

14. DATE OF CURRENT:

ILLNESS (First Symptom) OR

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS,

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

MM

DD YY

INJURY (Accident) OR

GIVE FIRST DATE

MM

DD

YY

MM

DD

YY

MM

DD

YY

PREGNANCY (LMP)

FROM

TO



17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

17a.

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

MM

DD

YY

MM

DD

YY

17b.

NPI#

FROM

TO

19. RESERVED FOR LOCAL USE

20. OUTSIDE LAB?

$CHARGES

YES

NO

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1,2,3 or 4 to Item 24E by Line)

22. MEDICAID RESUBMISSION

CODE

ORIGINAL REF. NO.

1.

.

3.

.

23. PRIOR AUTHORIZATION NUMBER

2.

.

4.

.

24. A.

DATE(S) OF SERVICE

B.

C.

D. PROCEDURES, SERVICES, OR SUPPLIES

E.

F.

G.

H.

I.

J.

From

To

Place of

(Explain Unusual Circumstances)

DIAGNOSIS

DAYS

EPSDT

ID.

RENDERING

MM

DD

YY

MM

DD

YY

Service

EMG

CPT/HCPCS

MODIFIER

POINTER

$CHARGES

OR

Family

QUAL.

PROVIDER ID.#

UNITS

Plan

NPI #

NPI #

NPI #

NPI #

NPI #

25. FEDERAL TAX I.D. NUMBER

SSN EIN

26. PATIENT’S ACCOUNT NO.

27. ACCEPT ASSIGNMENT?

28. TOTAL CHARGE

29. AMOUNT PAID

30. BALANCE DUE

(For govt. claims, see back)

YES

NO

$

$

$

31. SIGNATURE OF PHYSICIAN OR SUPPLIER

32. SERVICE FACILITY LOCATION INFORMATION

33. BILLING PROVIDER INFORMATION & PHONE #

INCLUDING DEGREES OR CREDENTIALS

(I certify that the statements on the reverse

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

SIGNED

DATE

a.

NPI

b.

a.

NPI

b.