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. Claim Forms Fill Out And Sign Printable Pdf Template Signnow 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 t...