Commercial

Insurance

Block
1
1a

BCBS

Medicare

x - other for ind/family plan

x - group plan
ID #

Pt's name LAST, FIRST, MI

PT DOB: MM DD YYYY :X Box

appropiarate for gender

Policy holders: LAST, First, MI

NO 'X' ON ANY

PT Mailing Address & Phone

SAME

X for patient relation to policy

holder

7
8

Policy holder mailing address

and phone #
Leave Blank

complete only with secondary

9, 9a, 9d insurance
9b-9c
Leave Blank

10 a-c
10d
11
11a
11b
11c

X for pt condition is related ti

accident: work, auto etc
Leave Blank
policy holder group ID #
policy holder DOB
leave blank
Name of policy holders
commercial health plan

TYPE NONE
BLANK

BLANK

BLANK

11d
12
13

IX in nO if there is no 2nd
insurance
SIGNATURE ON FILE
SIGNATURE ON FILE

14

MM DD YYY of visit/ symptoms

15

MM DD YYY of prior episode I

applies

16

MM DD YYYY time pt was not

able to work

17
17a
17b

First MI Last credentials of

referral
leave blank
NPI of referred provider

18
19
20
21

Admin date and discharge MM

DD YYYY
leave blank
X for NO: Outside Lab
ICD 10 codes up to 12

22
23

leave blank
prior auth of referral #

24
24B
24C

procedure from MM DD YYYY

POS 2 digit code
Leave Blank

24D

CPT or HCPCS II code with

modifier

24E

Diagnosis pointer from block

21

24F

fee charged for each service

enter address of location of service

24G
24H
24I
24J
25

Number of days for the service

leave blank
leave blank
10 digit NPI
EIN or SSN for provider

26

pt acct # assigned by provider

27

X for YES: accepts assigment

28
29-30

total chargers for

service/procedures
leave blank

31

provider name a credential

32

name & address of service and

provider

32a
32b

10 digit NPI as enterd in block

32
leave blank

33
33a
33b

billing provider name and

address
10 digit NPI of billing provider
Leave Blank

Medicaid

Tricare

NO 'X' ON ANY

NO 'X' ON ANY

TYPE SAME

BLANK

policy holder DOB

BLANK

BLANK

Worker's Comp

enter address of lacation of service