Monday, February 4, 2013

i Dont Know

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.

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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

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