Call Back# 877-215-6331 Primary Payer: Aetna Secondary Payer: UHC

Extn#2345 Address: PO Box 981106 El Paso Texas - Address: PO Box 4579 Houston Texas - 75211
79998 - 1106 Payer ID# ------
Fax # 800-123-1234 Payer ID# 57608 Contact# 800 456 7893
Atten: Dr.Shelby Richardson Contact# 888-632-3862 Secondary Policy ID# 815678459
Primary Policy ID# W789216712 Group# ------
HEALTH INSURANCE CLAIM FORM Group# 8946431 / PIN# ZH23187
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02112 Susan's SSN# 213-48-6759
Glenn's SSN# 213-48-6759
PICA I I I
I I I FICA
1. MEDICARE MEDICAID TRI CARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1)
HEALTH PLAN BLK LUNG
(Medicare#) (Medicaia) (IDA/DoD#) (Member ID49 (ID#) (ID#) (ID#) W789216712
2. PATIENT'S NAME (Last Name, Rrst Name, Midde Initial) 3. PATIENTS BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial)
MM I DD 1 YY
09 I 12 I 1983 F
M
L Roberts, Glenn
5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street)
908, Chamber Lane, Self Spouse Child Other 908, Chamber Lane,
CITY STATE 8. RESERVED FOR NUCC USE CITY STATE

ED INFORMATION
Dallas TX Dallas TX
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)

75284 ( ) 523 123 4567 75284 ( ) 523 123 4567

9. OTHER INSURED'S NAME (Last Name, Rrst Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER
8946431

lunsm
a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH SEX
MM I DD 1 YY
YES NO 03 01 I
I I 1982 M
F L
b. RESERVED FOR NUCC USE

PATIENT AND I
b. AUTO ACCIDENT? b. OTHER CLAIM ID (Designated by NUCC)
PLACE (State)
YES NO 1
1 I
c. RESERVED FOR NUCC USE c OTHER ACCIDENT? c. INSURANCE PLAN NAME CR PROGRAM NAME

YES NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES (Designated by NUCC) d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

I I YES NO If yes, complete items 9, 9a, and 9d.

READ BACK OF FORM BEFORE COMPLETNG & SIGN NG THIS FORM. 13. INSURED'S OR AUTHORIZED PERSONS SIGNATURE I authorize
12. PATIENT'S CR AUTHORIZED PERSON'S SIGNATURE I authorize The release of any medical or other information necessary payment of medical benefits to the undersigned ph ysid an or supplier for
to process this claim. I also regJest pa yment of government benefits either to myself or to the party inhoaccepts assignment services described felon.
felon.

SIGNED
Signature On File DATE
02-04-2020 SIGNED
Signature On File
14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP) 15. OTHER DATE 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM I DD I YY I I MM 1 DD 1 YY MM I DD I YY MM I DD I YY
02 04
I I QUAL.1
QUAL. I
I I I
FROM I I
I
TO
I
I
I
17. NAME OF REFERRING PROVIDER CR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM I DD I YY MM I DD I YY
I
Sean Harris 17b NPI 1431256353 FROM
I I
TO I
I
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUT SIDE LAB? $ CHARGES

YES NO
21. DIAGNOSIS CR NATURE OF ILLNESS CR INJURY Relate A-L to service line felon (24E) i 22. RESUBMISSION
ICD Ind. II CODE ORIGINAL REF. NO.
A. I L40.50 B. I c I D I
23. PRIOR AUTHORIZATION NUMBER
E. 1 F. 1 G. 1 H
I. 1 J. 1 K 1 L. Authorization - 19R191511

PHYSICIAN OR SUPPLIIER INFORMATION

24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, CR SUPPLIES E. F. G. I. J.
AYS
Ea

From To [LACE CIF (Explain Unusual Circumstances] DIAGNOSIS D ID. RENDERING

MM DD YY MM DD YY SERVICE EMG CPT/HCPCS I MODIFIER POINTER $ CHARGES PROVIDER ID. #
g

UNITS QUAL

ZH23187
I
170.00
- - - -
12 27 12 27 11 96372 1
LT A i
1 NPI 1234567890
50474-710-79 ZH23187
12 27 12 27 11 J0717 A 4800.00 1 NPI 1234567890

NPI

NPI

NPI

- - - -

1 NPI
25. FEDERAL TAX I.D. NUMBER SSN El N 26. PATIENTS ACCOUNT NO. 27.gicEfjcltraS12:1NIZ.IT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. Rsvd.for NUCC Use
152-64-7839 P M123456 I YES I INC'
$ 0.00
I
I $ 0.00 I
i
(

31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # 1(
INCLUDING DEGREES CR CREDENTIALS )
125, South Blvd, Get-well soon Clinic
(I certify that the statements on The reverse
apply to this till and are made a part thereof.) Westin Dr, Dallas P.O. Box - 1234, Heaven City,
Richardson, Shelby TX - 75266-0044 TX - 75284
a. 1234567890 b. a. 1023987645 b.
4

SIGNED DATE
NUCC Instruction Manual available at: www.nucc.org PLEASE PRINT OR TYPE - -

837 Sent to Aetna on 02/13/20 Clear Form