sJ)

MEDICAL CLAIM FORM

READ DIRECTIONS BEFORE COMPLETlNG

PATIENrS
(FI,st

name.

middle

OR SIGNING THIS FORM

NAME
name)

initial. last

"D A-N

AUTHORIZATION

SVV(""'lvJ

'S .

I~L.

TO PAY

I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED

PHYSICIAN OR SUPPLIER ,FOR SERVIC~ DESCRIBED.

SIGNED (AuIhorlzed Person/

'i

DATE

rs:,.-::e c2-

PHYSICIAN OR SUPPLIER INFORMATION

..

14. DATE OF:

ILlNESS (FIRST SYMPTOM) OR

INJURY (ACCIDENT) OR
.'
PREGNANCY (LMP)

16. HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS?

YES!
INO
!
OATES OF PARTIAL DISABILITY

18, OATES OF TOTAL DISABILITY

17. DATE PATIENT ABLE TO

RETURN TO WORK

FROM
1~. NAME OF REFERRING PHYSICIAN

o._~~

DATE FIRST CONSULTED

', . YOU FOR THIS CONOlTION

ITH~OUGH

FROM
jTHROUGH
20. FOR SERVICES RELATED TO HOSPITALIZATION
GIVE HOSPITALIZATION DATES
ADMITTED
jDISCHARGED
22. WAS I.A8OAATORY WORK PERFORMED OUTSIDE YOUR OFFICE?

21. NAME & ADDRESS OF FACILITY WHERE SERVICES RENDERED (N other than hOme or office/

YES
23.. DIAGNOSIS OR NATURE OF ILlNESS OR INJURY. RELATE DIAGNOSIS TO PROCEOUBE IN COlUMN

D 8Y REFERENCE TO NUMBERS 1:2.3.

! CHARGES;
!NO
ETC. pR OX CODE

1.

2.-_-_-

'.

..t

3.
4.
24.

A
DATE OF
SERVICE

p~r
S

B"

V
I E

PROCEDURE CODE
(IDENTIFY;
)

..

FULLY DESCRIBE PROCEDURES. MEDICAL SERVICES OR SUPPliES

FURNISHED FOR EACH DATE GIVEN
(EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES)

DIAGNOSIS
CODE

CHARGES

--

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---

------------

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,------------

---

.-----------:

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---

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25. SIGNATURE OF PHYSICIAN OR SUPPLIER

2&. ACCEPT ASSIGNMENT

26. AMOUNT PAIDl28.

BALANCE DUE

YES

JNO
30. YOUR SOCIAL SECURITY NO.

SIGNED

27. TOTAL CHARGE

31. PHYSICIAN'S OR SUPPLIER'S NAME. ADDRESS. ZIP CODE'

TELEPHONE NO.
.

DATE

32. YOUR PATIENT'S ACCOUNT NO.

33. YOUR EMPlOYER

1.0. NO.

I.D.NO.

----

PLACE OF SERVICE CODES

1 - (IH) - INPATIENT HOSPITAL
2 - (OH) - OUTPATIENT HOSPITAL
3 - (0)
- DOCTOR'S OFFICE

4 - (H) - PATIENrS
56-

HOME

DAY CARE FACILITY (PSy)

NIGHT CARE FACiliTY (PSy)

7 - (NH)

- NURSING HOME

8 - (SNF) - SKILLED NURSING FACILITY

9 AMBULANCE

o - (Ol)
A - (IL)

- OTHER LOCATIONS
- INDEPENDENT LABORATORY

BIiInnn"'"e,.."v

OTHER MEDICAl/SURGICAL
II

,..,,..,

,.. .......

~,...,..".

FACILITY

I"O~"'H"'~"".

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