Omb 0938 1197 Form 1500
Please print or type approved omb 0938 1197 form 1500 02 12 key. Insured s policy group or feca number a.
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Patient relationship to insured.
Omb 0938 1197 form 1500. The renewal of the 1500 claim form by omb occurs every three years and is outside the scope of the nucc s work. Insured s name last name first name middle initial 7. Centers for medicare medicaid services.
Instructions for completing owcp 1500 health insurance claim form for medical services provided under the federal employees compensation act feca the black lung benefits act blba and the energy employees occupational illness. Forms with the 02 12 nucc approval date and omb number 0938 1197 02 12 remain in effect and valid. 7500 security boulevard.
Number for program in item 1 4. Insured s address no street city state zip code telephone include area code 11. Insured s or authorized person s signature i authorize payment of medical benefits to the undersigned physician or supplier for services described below.
Please print or type approved omb 0938 1197 form 1500 02 12. New 2500 cms 1500 claim forms current hcfa 02 2012 version omb 0938 1197 forms will line up with billing software and laser compatible 2500 sheets 8 5 inch x 11 5 0 out of 5 stars 15 46 99 46. Reserved for nucc use zip code.
Approved omb 0938 1197 form 1500 02 12 13. The form has been renewed in its current format with no changes to the omb number data fields or other text on the form. Health insurance claim form.
Cms 1500 form cms 1500. A federal government website managed and paid for by the u s. R required in filing a claim nr not required not used s situational only used if appropriate specific to claim 1.
Approved omb 093b 1197 form cms 1500 06 15 omb no. Illness injury or pregnancy lmp qual. Insured s date of birth b.
Nucc instruction manual available at. Patient s birth date mm dd 6. Type of health insurance coverage 1a.
Insured s id number enter the insured s 8. Approved omb 0938 1197 form 1500 02 12 1a. Please print or type approved omb 0938 1197 form 1500 02 12.
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