Claim Forms & Patient Valuables Bags
B.
A.
PICA APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 HEALTH INSURANCE CLAIM FORM
C.
PICA
1. MEDICARE
MEDICAID (Medicaid #)
TRICARE (ID#/DoD#)
CHAMPVA (Member ID#)
GROUP HEALTH PLAN (ID#)
FECA BLK LUNG (ID#)
OTHER
1a. INSURED’S I.D. NUMBER
(For Program in Item 1)
(Medicare #)
(ID#)
SEX
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
3. PATIENT’S BIRTH DATE MM DD YY
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
F
M
5. PATIENT’S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED’S ADDRESS (No., Street)
Self
Spouse
Child
Other
CITY
STATE
8. RESERVED FOR NUCC USE
CITY
STATE
TELEPHONE (Include Area Code) ( )
TELEPHONE (Include Area Code) ( )
ZIP CODE
ZIP CODE
9. OTHER INSURED’S NAME (Last Name. First Name, Middle Initial)
10. IS PATIENT’S CONDITION RELATED TO:
11. INSURED’S POLICY GROUP OR FECA NUMBER
SEX
a. INSURED’S DATE OF BIRTH
a. OTHER INSURED’S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (Current or Previous)
MM DD YY
M
F
YES
NO
b. AUTO ACCIDENT?
b. OTHER CLAIM ID (Designated by NUCC)
b. RESERVED FOR NUCC USE
PLACE (State)
NO
YES
c. INSURANCE PLAN NAME OR PROGRAM NAME
c. RESERVED FOR NUCC USE
c. OTHER ACCIDENT?
YES
NO
10d. CLAIM CODES (Designated by NUCC)
d. INSURANCE PLAN NAME OR PROGRAM NAME
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
If yes, complete items 9, 9a and 9d.
YES
NO
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13.
INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below.
SIGNED
SIGNED
DATE
14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP) 15.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
OTHER DATE
MM DD YY
MM DD YY
MM DD YY
MM DD YY
FROM
TO
QUAL.
QUAL.
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
17a.
MM DD YY
MM DD YY
FROM
TO
17b. NPI
$ CHARGES
20. OUTSIDE LAB?
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (Relate A-L to service line below (24E)
22.
RESUBMISSION CODE
ICD Ind.
ORIGINAL REF. NO.
A.
B. J. F.
C.
D.
23. PRIOR AUTHORIZATION NUMBER
E.
K. G.
L. H.
I.
A.
E.
F.
G.
H.
I. ID. QUAL.
J. RENDERING PROVIDER ID. #
24.
B. PLACE OF SERVICE
C.
D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances)
DATE(S) OF SERVICE
From
To
DIAGNOSIS POINTER
DAYS OR UNITS
EPSDT Family Plan
$ CHARGES
EMG
MM DD YY
MM DD YY
CPT/HCPCS
MODIFIER
1
NPI
2 3 4 5 6
NPI
NPI
NPI
NPI
NPI
28. TOTAL CHARGE
29. AMOUNT PAID
30. Rsvd for NUCC use
27.ACCEPT ASSIGNMENT? (For govt. claims, see back)
25. FEDERAL TAX I.D. NUMBER
26. PATIENT’S ACCOUNT NO.
SSN EIN
YES
NO
$
$
( )
33. BILLING PROVIDER INFO & PH. #
32. SERVICE FACILITY LOCATION INFORMATION
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.)
NPI
NPI
a.
b.
a.
b.
SIGNED
DATE
APPROVED OMB 0938-1197 FORM 1500 (02-12)
PLEASE PRINT OR TYPE
NUCC Instruction Manual available at: www.nucc.org
WCMS-1500CS-12
Features
Claim Forms
Patient Valuables Bags
Patient Valuables Envelopes • 3-part form/envelope • Tear off receipt on page one for patient to claim their belongings • Consecutively numbered • Heavy-duty paper
• 81/2" x 11" 1-Part forms • 91/2" x 11" 2-Part forms • CMS1500 and UB04 claim forms in OCR Red ink • ADA forms in Black (OCR red for use with Alaska Medicaid claims only) • Most up-to-date forms required for claim submission
• Tamper-evident • Imprint color: Reflex Blue • .003 mil low-density polyethylene • Tear off receipt on top for patient to claim their belongings • Consecutively numbered
• 2500 per carton (1-part forms) • 1000 per carton (2-part forms) • Guaranteed compliance
1
Claim Forms
Item Number
Description
2,500 $80.90 $80.90 $80.90 $80.90 $80.90
VWH-HF5-NS24 Laser ADA Claim Form 2024 Version
VWH-HF6-NS24 Laser ADA Claim Form 2024 Version for Alaska Medicaid
VWH-HF1-NS24 1-pt Continuous UB04 form
VWH-HF3-NS24 Laser UB04 Claim Form
A. VWH-HF12-NS24 Laser CMS1500 Claim Form 2012 Version
Item Number
Description
1,000 $87.51
VWH-HF2-NS24 2-Part Continuous UB04 Form
(R) Production time: 1 working day. 1-Part forms; 2500 per carton and 2-Part forms; 1000 per carton.
Patient Valuables Bags & Envelopes
Item Number
Description
500
1,000
2,500
5,000 10,000
B. VWH-H24-NS24 C. VWH-H25-NS24
9" X 12" Patient Valuables Envelope, White Heavy Duty Paper
$305.45 $305.45 $305.45
$607.61 $607.61 $607.61
$1,484.34 $1,484.34 $1,484.34
$2,905.94 $2,905.94 $2,905.94
$5,694.66 $5,694.66 $5,694.66
10" X 13” Patient Valuables Bag, Clear Polyethylene
VWH-H28-NS24
10" X 13” Patient Own Medication bag, clear polyethylene
(R) Production time: 1 working day. 500 per carton.
122
Manufactured in the USA
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