Appendix C
1. MEDICARE (Medicare #) MEDICAID (Medicaid #) TRICARE CHAMPUS (Sponsors SSN) CHAMPVA (Member ID #) GROUP health PLAN (SSN or ID) FECA BLK LUNG (SSN) OTHER (ID) SEX M 1a. INSUREDS I.D. # (For schedule in Item 1)
12345678910
4. INSUREDS NAME (Last Name, commencement Name, MI) F
2. PATIENTS NAME (Last Name, get-go Name, MI)
Brown, James
5. PATIENTS ADDRESS ( #, Street)
3. PATIENTS BIRTH figure MM DD YY
02
01
1940
Child Other
Brown, James
7. INSUREDS ADDRESS ( #, Street)
6. PATIENT family TO INSURED Self Spouse 8. PATIENT STATUS iodine Employed
CITY
STATE
PH O EN
CITY
1600 Pennsylvania Ave
Washington
ZIP CODE
1600 Pennsylvania Ave
DC
earphone (Include sports stadium Code)
Married Full-Time Student
Other
Washinton
ZIP CODE
TELEPHONE (Include Area Code)
6000
( N/Y ) N/Y
Part-Time Student
6000
( n/a ) n/a
9. OTHER INSUREDS NAME (Last Name, First Name, MI)
10. IS PATIENTS CONDITION RELATED TO:
11. INSUREDS POLICY GROUP OR FECA #
na
a. OTHER INSUREDS POLICY OR GROUP # a. EMPLOYMENT? (Current of Previous) YES SEX M F b. AUTO ACCIDENT? YES c. OTHER ACCIDENT? YES 10d. topical anaesthetic USE NO NO NO
1098765
a. INSUREDS DATE OF BIRTH
N/A
b.
INSUREDS DATE OF BIRTH MM DD YY
02
MM
0
DD
1940
YY
M
PLACE (State)
b. EMPLOYERS NAME OR SCHOOL NAME
02
n/a
01
1940
DC
n/a n/a
c. EMPLOYERS NAME OR SCHOOL NAME
c. INSURANCE PLAN NAME OR architectural plan NAME
d. INSURANCE PLAN NAME OR PROGRAM NAME
d. HEALTH BENEFIT PLAN? YES NO
n/a
n/a
If yes, return to and gross(a) item 9 a-d.
14. DATE OF CURRENT: MM DD YY
06
01
1940
unwellness (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP)
15. IF PATIENT HAS HAD akin OR SIMILAR ILLNESS. GIVE FIRST DATE MM DD YY
O
SIGNED
SOF
F
READ BACK OF FORM BEFORE COMPLETING & sign language THIS FORM. 12. PATIENTS OR AUTHORIZED PERSONS SIGNATURE
13. INSUREDS OR AUTHORIZED...If you requirement to get a full essay, order it on our website: Orderessay
If you want to get a full essay, wisit our page: write my essay .
No comments:
Post a Comment