J_t

MEDICAL CLAIM FORM

READ DlREOTlONS BEFORE OOMPLE11NG OR SIGNING THIS FORM

PATIENT'S NAME
(First

name,

initial, last name)

middle

s. S ULt-1 V A-N

DA-N':L
AUTHORIZATION

TO PAY

I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED PHYSICIAN OR SUPPUER FOR SERVICE DESCRIBED.

SIGNED (Authorized Pwson)

DATE

PHYSICIAN OR SUPPLIER INFORMATION

...

14. DATE OF:

1'5.

ILLNESS (FIRST SYMPTOM) OR

INJURY (ACCIDENT)' OR
PREGNANCY (LMP)

17. DATE PAllENT ABLE TO

RETURN TO WORK

see... a..

eel--

~(!..~

III. HAS PATIENT EVER HAO SAME OR SIMILAR SYMPTOMS?

DATE FIRST CONSULTED

YOU FOR THIS CONDITION

lNO

YEsl
OATES OF PARTIAL DISABILITY

18. DATES OF TOTAL DISABILITY

FROM
111.NAME OF REFERRING PHYSICIAN

THROUGH
FROM
20. FOR SERVICES RELATED TO HOSPITALIZATION
GIVE HOSPITALIZATION OATS

THROUGH

AOMmEO
DISCHARGED
22 .. WAS LABOAATc;>RY WORK PERFORMED OUTSIDE YOUR OFFICE?

21. NAME & ADDRESS OF FACILITY WHERE SERVICES RENDERED (II other than hOme or oIfIce)

YES
23. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, RELATE OIAGNOSIS TO PROCEDURE IN COlUMN

I I.

I CHARGES:

INO

0 BY REFERENCE TO NUMeERS t, 2, 3, ETC. OR OX COOE

T
"

2.

...

("

3.

4.
24.

A
DATE OF
SERVICE

o -

FUllY DESCRIBE PROCEDURES. MEDICAL SERVICES OR SUPPLIES

.
FURNISHED FOR EACH DATE GIVEN
PROCEDURE CODE
(IDENTIFY:
)
(EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES)

w-

P~E
S

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

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

DIAGNOSIS
COOE

CHARGES
I

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

------

~---------- ------------------

-----

---------- -----------------..

...

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~
,
-----------------._------------- ---------- ------------------------------ ------ ---------- -----------------,
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. _------------- ---------- ----------------------------------- ---------- -----------------.------------ --- ---------- ---------------------------------- ---------- -----------------r

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....

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.
25. SIGNATURE OF PHYSICI""

OR SyPPLIER

28. ACCEPT ASSIGNMENT

27. TOTAL CHARGE

"

YES

30. YOUR SOCIAL SECURITY

INO
NO.

. 28. AMOUNT PAID

I
I
I

31. PHYSICIAN'S OR SUPPliER'S

TELEPHONE NO.

128. BAL.AHC~ DUE

NAME, ADDRESS, ZIP COOE ,

DATE

SIGNED
32. YOUR PATIENT'S ACCOUNT

NO.

33. YOUR EMPlOYER

1.0.

NO.

,
,(
E

.. .

1.0. NO.

r . f

,.."nrC'"

1 - (IH) - INPATIENT HOSPITAL

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

4 - (H) - PATIENTS HOME

56 -

DAY CARE FACILITY (PSy)

NIGHT CARE FACILITY (PSy)

7 - (NH) - NURSING HOME

8 - (SNF) - SKILLED NURSING FACILITY
9AMBULANCE

o - (OL)

- OTHER LOCATIONS

A - (IL)
B -

- INDEPENDENT LABORATORY
OTHER MEDICAUSURGICAL FACILITY