Please help me I am so lost..thank you!?

Complete a CMS-1500 Claim Form If you believe information provided in the following list is insufficient to adequately fill a required field with data, for example, to supply a specific diagnosis code, indicate this by typing N/A. If no patient information has been given for a specific field, leave it blank. Name: Katherine Doe Insurer: TRICARE Policy Number: 123456 ID number: 999000666 DOB: 01/01/1950 Gender: Female Insured: James Doe, spouse Address: 1111 Noname Court, Nowhere, NY 22222 Marital Status: Married Patient鈥檚 Employer: Homemaker Spouse鈥檚 Employer: U.S. Army Nature of Condition: Routine exam Patient Signature



Appendix C

1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER

CHAMPUS HEALTH PLAN BLK LUNG

(Medicare #) (Medicaid #) (Sponsor鈥檚 SSN) (Member ID #) (SSN or ID) (SSN) (ID)

1a. INSURED鈥橲 I.D. # (For Program in Item 1)

3. PATIENT鈥橲 BIRTH DATE SEX

2. PATIENT鈥橲 NAME (Last Name, First Name, MI)

MM

DD

YY

M F

4. INSURED鈥橲 NAME (Last Name, First Name, MI)

5. PATIENT鈥橲 ADDRESS ( #, Street)

6. PATIENT RELATIONSHIP TO INSURED

Self Spouse Child Other

7. INSURED鈥橲 ADDRESS ( #, Street)

CITY

STATE

CITY STATE

ZIP CODE

TELEPHONE (Include Area Code)

( )

8. PATIENT STATUS

Single Married Other

Employed Full-Time Part-Time

Student Student

ZIP CODE

TELEPHONE (Include Area Code)

( )

9. OTHER INSURED鈥橲 NAME (Last Name, First Name, MI)

10. IS PATIENT鈥橲 CONDITION RELATED TO:

11. INSURED鈥橲 POLICY GROUP OR FECA #

a. INSURED鈥橲 DATE OF BIRTH SEX

a. OTHER INSURED鈥橲 POLICY OR GROUP #

a. EMPLOYMENT? (Current of Previous)

YES NO

MM

DD

YY

M F

b. INSURED鈥橲 DATE OF BIRTH SEX

PLACE (State)

MM

DD

YY

M F

b. AUTO ACCIDENT?

YES NO

b. EMPLOYER鈥橲 NAME OR SCHOOL NAME

c. EMPLOYER鈥橲 NAME OR SCHOOL NAME

c. OTHER ACCIDENT?

YES NO

c. INSURANCE PLAN NAME OR PROGRAM NAME

d. INSURANCE PLAN NAME OR PROGRAM NAME

10d. LOCAL USE

d. HEALTH BENEFIT PLAN?

YES NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING %26amp; SIGNING THIS FORM.

12. PATIENTS OR AUTHORIZED PERSON鈥橲 SIGNATURE

SIGNED DATE .

13. INSUREDS OR AUTHORIZED PERSON鈥橲 SIGNATURE

SIGNED .

14. DATE OF CURRENT:

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

MM

DD

YY

ILLNESS (First symptom) OR

INJURY (Accident) OR PREGNANCY (LMP)

GIVE FIRST DATE MM

DD

YY

MM

FROM

DD

YY MM

TO

DD

YY

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

17a.

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

17b.

NPI

MM

FROM

DD

YY MM

TO

DD

YY

20. OUTSIDE LAB? $CHARGES

19. RESERVED FOR LOCAL USE

YES NO

22. MEDICADE RESUBMISSION

CODE ORIGINAL REF. #

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

1. | . . 3. | . .

2. | . . 4. | . .

23. PRIOR AUTHORIZATION #

D. PROCEDURES, SERVICES, OR SUPPLIES

(Explain Unusual Circumstances)

24. A. DATE(S) OF SERVICE

From To

MM DD YY MM DD YY

B.

PLACE OF

SERVICE

C.

EMG

CPT/HCPCS

MODIFIER

E.

DIAGNOSIS

POINTER

(1, 2, 3, or 4)

F.

$ CHARGES

G.

DAYS

OR

UNITS

H.

EPSDT

Family

Plan

I.

ID.

QUAL.

J.

PROVIDER ID. #

NPI

NPI

NPI

NPI

28. TOTAL CHARGE

29. AMOUNT PAID

30. BALANCE DUE

27. ACCEPT ASSIGNMENT?

(For govt. claims, see back)

25. FEDERAL TAX I.D. # SSN EIN

26. PATIENT鈥橲 ACCOUNT #

YES NO

$

$

$

32. SERVICE FACILITY LOCATION INFORMATION

33. BILLING PROVIDER INFO %26amp; PH #

( )

31. SIGNATURE OF PHYSICIAN OR SUPPLIER

INCLUDING DEGREES OR CREDENTIALS

SIGNED DATE

a.

b.

a.Please help me I am so lost..thank you!?
your question is too long and confusing. good luck if anyone actually answers