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1500 Claim Form Assignment Essay

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Appendix C
MEDICAID
(Medicaid #)

TRICARE
CHAMPUS
(Sponsor’s SSN)

CHAMPVA
(Member ID #)

2. PATIENT’S NAME (Last Name, First Name, MI)

GROUP
HEALTH PLAN
(SSN or ID)

FECA
BLK LUNG
(SSN)

3. PATIENT’S BIRTH DATE
MM
DD
YY

Doe, Katherine

01

01

5. PATIENT’S ADDRESS ( #, Street)

1111 Noname Court
CITY

STATE

Nowhere

NY

ZIP CODE

TELEPHONE (Include Area Code)

22222

(

OTHER

1a. INSURED’S I.D. #

(ID)

999000666

SEX
M

4. INSURED’S NAME (Last Name, First Name, MI)
F

Doe, James

1950

6. PATIENT RELATIONSHIP TO INSURED

7. INSURED’S ADDRESS ( #, Street)

Self
Spouse
8. PATIENT STATUS

CITY

Single

Child

1111 Nona...

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Keywords

01 1 10 10d 11 1111 12 123456 13 14 15 1500 16 17 17a 17b 18 19 1950 1a 2 20 21 22 22222 23 24 25 26 27 28 29 3 30 31 32 33 4 5 6 7 8 9 999000666 a-d accept accid account address amount appendix area armi assign author auto b back balanc benefit bill birth blk c champus champva charg child circumst citi claim code complet condit court cpt/hcpcs credenti current d date day dd degre diagnosi doe due e ein emg employ en epsdt er explain f facil famili feca feder file first form full full-tim g give govt group h health hospit i.d id ill includ info inform injuri insur item iv ix j jame katherin lab last lmp local locat lung m marri medicad medicaid medicar member mi mm modifi name natur nonam nowher npi ny o occup origin outsid paid part part-tim patient person ph physician place plan pointer polici pregnanc previous prior procedur program provid qual read ref refer relat relationship reserv resubmiss return school see self servic sex si sign signatur similar singl sourc sponsor spous ssn state status street student suppli supplier symptom tax telephon time total tricar ty u.s un unabl unit unusu use v70.0 work yes yy zip