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Get and Sign Approved OMB 0938 0999 Form CMS 1500 08 05 Approved OMB 0938 0999 Form CMS 1500 08 05 2005-2022
CHAMPVA Member ID 3. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 17a. 17b. SERVICE FACILITY LOCATION INFORMATION a. NUCC Instruction Manual available at www. nucc.org b. 28. TOTAL CHARGE 29. NPI 20. OUTSIDE LAB 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items 1 2 3 or 4 to Item 24E by Line CHARGES 22. D. NUMBER FECA BLK LUNG SSN ID 4. INSURED S NAME Last Name First Name Middle Initial SEX M 5. PATIENT S ADDRESS No. Street F 6....
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