1

2
3
4
5
6
7
8
9
10
11
12

Block

Commercial
Insurance

BCBS

Medicare

Medicaid

Tricare

Worker's Comp

1
1A

15
16
17
18
19
20
21
22
23
24
25
26
27

31
32
33

37
38

41
42

46
47
48
49
50

Policy holder's Last Name, First

Name, Initial
Pt's Address and Phone #

Leave blank.

Leave Blank.

EMPLOYER NAME

Pt's relationship to
policyholder, mark w/X

Leave blank.

Leave Blank.

X-OTHER

Policyholder's Address &

Phone#
LEAVE blank, NCCU.
Other insurance name
Leave blank.

Leave
Leave
Leave
Leave

Leave Blank.
Leave Blank.

EMPLOYER'S ADDRESS

7
8
9, 9A, 9D
9B-9C

10A-C
10D

54
55
56

blank.
blank.
blank.
blank.

X for Pt condition related to

auto, employment, or accident.
Leave blank.

11
11A

policy holders commercial

group number
policy holders DOB

10-A X- YES
IF DD FORM 2527 ATTACHED
Enter NONE
Leave blank.

Leave Blank.
Leave Blank.

LEAVE BLANK
LEAVE BLANK

9-DIGIT FECA #
LEAVE BLANK

11B

Leave blank, workers comp.

claim

Leave Blank.

LEAVE BLANK

CLAIM # WC THIRD PARTY

11C

NAME policy holders

commercial insurance plan

Leave blank.

Leave Blank.

LEAVE BLANK

NAME OF WORKERS COMPENSATION PAYER

11D

X-if no 2nd insurance coverage

Leave blank.

Leave Blank.

LEAVE BLANK

Leave blank.

Leave blank.

Leave Blank.
Leave Blank.

LEAVE BLANK
LEAVE BLANK

Leave blank.

12
13

enter signature on file (SOF)

SOF

14

Date of S&S, QUAL 431 IF

PREGNANT 484

15

DATE PRIOR EPISODES OF

SAME ILLNESS

Leave blank.

16

Leave blank or DATE PT IS

UNABLE TO WORK

Leave blank.

17
17A

Name of referring physician:

DN, DK, DQ.
Leave blank.

17B

referring physician 10-digit NPI

18
19
20

Hospital admission date &

discharge related to current
illness
LEAVE BLANK
X-no for outside labs

21
22

ICD-10-CM CODES, A-L, ICD

indicator "0"
LEAVE BLANK

23

Prior authorization numbers

24A
24B
24C

FrM: DATE PROCEDURE

PERFORMED TO: IF
PROCEDURE PERFORMED ON
CONSECUTIVE DAYS
PLACE OF SERVICE
LEAVE BLANK

24D

Enter CPT or HCPCS level ll and

midifier

24E

Enter diagnosis pointer from

Block21

24F
24G

Fee charge for ea. Reported

procedure from Block21
days or units

24h
24I

Leave blank. Reserved for

Medicare forms.
Leave blank.

24J
25
26

Leave blank, unless provider is

a member of group practice
(NPI)
Providers EIN
Pt's account #

27

Accept assignment X-yes or no

28

Total charhges from block24.

29
30

Leave blank, enter amt. pt.

paid for service
Leave blank.

31

Provider's name & credentials,

date.

51
52
53

PATIENT SOCAIL SECURITY

4
5

43
44
45

X-IN FECA DEFC OR X-OTHER

Pt's birth date MM DD YYYY &

X-gender

39
40

X-TRICARE/CHAMPUS

34

35
36

X- Medicaid

Pt's name LAST, FIRST, MI

28
29
30

X- Medicare box

ID #

13
14

x - other for ind/family plan

x - group plan

32
32A
32B
33
33A
33B

Providers name & address if

services provided at another
location
10-digit NPI
Leave blank.
Provider's billing name,
address, telephone #.
10-digit NPI of the billing
provider
Leave blank.

Leave Blank.
Leave Blank.
Leave Blank.

E-emergency or leave blank.

Leave blank.
Leave blank.

LEAVE BLANK