| Field |
Completion Instructions |
|
1
|
Health Insurance Coverage
(Located on the patient’s card Medicare, Medicaid, Champus, etc.)
|
|
1a
|
Medicare number
(Usually a social security number with a suffix)
|
|
2
|
Patient’s full name
|
|
3
|
Patient’s date of birth and sex
|
|
4
|
Insured’s name (Primary)
|
|
5
|
Patient’s address
|
|
6
|
Patient’s relationship to insured
|
|
7
|
Insured’s address
|
|
8
|
Patient’s relationship to insured
|
|
9
|
Other Insured’s name Medigap
|
|
10 a-c
|
Additional patient information (Patient’s employment, auto accident, other accident-- an MSP indicator)
|
|
11
|
Insured’s policy or group number ( Is Medicare Primary or Secondary? Enter none if Medicare is Primary)
|
|
11a
|
Insured’s date of birth and sex
|
|
11b
|
Employer’s Name
|
|
11c
|
Insurance plan name
|
|
11d
|
Is there another health
|
|
12
|
Patient’s Signature
|
|
13
|
Authorization for payment
|
|
14
|
Date of current illness
|
|
15
|
Date of similar illness (not necassary)
|
|
16
|
Dates patient unable to work in current occupation (not necassary)
|
|
17
|
Referring/Ordering Physician’s Name
|
|
17a
|
Unique Physician’s Identifier Number
(Enter if billing a diagnostic radiology service, diagnostic laboratory service, consultation)
|
|
18
|
Hospital Dates of Current Illness (not necassary for Medicare)
|
|
19
|
Reserved for local use ( Entering Low Osmolar Contrast Material (dosage amount); Split Care-relinquish datefor global surgery; more than 2 modifiers; routine foot care date last seen of attending
physician; Hospice-“Attending physician not a hospice employee”)
|
|
20
|
Outside Lab—Purchased Test ( Diagnostic tests subject to purchase prime limitations. Enter the purchase price under
charges if the yes Block is checked. A “yes” indicates that an entity other than the
entity billing has performed the diagnostic test.)
|
|
21
|
Diagnosis Codes
|
|
22
|
Medicaid Resubmission Code
(not necassary for Medicare)
|
|
23
|
Prior Authorization Number
(CLIA numbers, Mammography certificate number)
|
|
24
|
Date of service
|
|
25
|
Federal Tax Id
|
|
26
|
Patient’s Account
|
|
27
|
Accept Assignment?
|
|
28
|
Total Charge
|
|
29
|
Amount Paid
|
|
30
|
Balance Due
|
|
31
|
Signature of Physician/Supplier
|
|
32
|
Name/Address of Facility where services rendered
|
|
33
|
Physician number, name and address
|
|
|
|
