Hcr 220 Week 8 Checkpoint

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...