Submitted by: Submitted by Jen27
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Category: Other Topics
Date Submitted: 08/18/2011 02:02 PM
Appendix C
1. MEDICARE (Medicare #) MEDICAID (Medicaid #) TRICARE CHAMPUS (Sponsor’s SSN) CHAMPVA (Member ID #) GROUP HEALTH PLAN (SSN or ID) FECA BLK LUNG (SSN) OTHER (ID) SEX M 1a. INSURED’S I.D. # (For Program in Item 1)
999000666
4. INSURED’S NAME (Last Name, First Name, MI) F
2. PATIENT’S NAME (Last Name, First Name, MI)
Doe Catherine
5. PATIENT’S ADDRESS ( #, Street)
3. PATIENT’S BIRTH DATE MM DD YY
01
01
1950
Child Other
Doe James
7. INSURED’S ADDRESS ( #, Street)
6. PATIENT RELATIONSHIP TO INSURED Self Spouse 8. PATIENT STATUS Single Employed
CITY
STATE
PH O EN
CITY ZIP CODE
1111 Noname Court
Nowhere
ZIP CODE
NY
TELEPHONE (Include Area Code)
Married Full-Time Student
Other
TELEPHONE (Include Area Code)
22222
(
)
Part-Time Student
(
9. OTHER INSURED’S NAME (Last Name, First Name, MI)
10. IS PATIENT’S CONDITION RELATED TO:
11. INSURED’S POLICY GROUP OR FECA #
123456
MM
a. OTHER INSURED’S POLICY OR GROUP #
a. EMPLOYMENT? (Current of Previous) YES NO
a. INSURED’S DATE OF BIRTH DD YY
M
b. INSURED’S DATE OF BIRTH MM DD YY M c. EMPLOYER’S NAME OR SCHOOL NAME
SEX F
b. AUTO ACCIDENT? YES c. OTHER ACCIDENT? YES NO NO
PLACE (State)
b. EMPLOYER’S NAME OR SCHOOL NAME
U.S. Army
c. INSURANCE PLAN NAME OR PROGRAM NAME
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. LOCAL USE
d. HEALTH BENEFIT PLAN? YES NO
If yes, return to and complete item 9 a-d.
14. DATE OF CURRENT: MM DD YY
ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP)
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM DD YY
O
SIGNED
Signature on file
F
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENTS OR AUTHORIZED PERSON’S SIGNATURE
13. INSUREDS OR AUTHORIZED PERSON’S SIGNATURE
DATE
.
SIGNED
Signature on file
FROM
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD YY TO...