Fill and Sign the Sc Workers Compensation Form

YES NO YES NO YES NO YES NO If yes, return to and complete item 9 a-d. YES NO YES No                   (Medicaid #) (Sponsor's SSN) (VA File #) (SSN or ID) (SSN) (ID)                   F             Spouse Child Other                    Married Other                          Student Student                                     F                                     DATE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              PLEASE APPROVED OMB-0938-0008 DO NOTSTAPLEIN THISAREA PICA HEALTH INSURANCE CLAIM FORM PICA 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1) HEALTH PLAN BLK LUNG (Medicare #) 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial)M 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) Self CITY STATE 8. PATIENT STATUS CITY STATE Single ZIP CODE TELEPHONE (include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) Employed Full-Time Part-Time 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 a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH SEX M b. OTHER INSURED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME M F c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 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 assignmentbelow. payment of medical benefits to the undersigned physician or supplier forservices described below. SIGNED SIGNED 14 DATE OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION INJURY (Accident) OR GIVE FIRST DATE PREGNANCY(LMP) FROM TO 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSIONCODE ORIGINAL REF. NO. 1. 3. 23. PRIOR AUTHORIZATION NUMBER 2. 4. 24. A B C D E F G H I J K DATE(S) OF SERVICE Place Type PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSDTFamily RESERVED FOR From To of of CODE $ CHARGES OR Plan EMG COB Service Service CPT/HCPCS MODIFIER UNITS LOCAL USE 1 2 3 4 5 6 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27 ACCEPT ASSIGNMENT?(For Govt.. claims, see back) 29. TOTAL CHARGE 29- AMOUNT PAID 30. BALANCE DUE $ 31 . SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS(I certify that the statements on the reverseapply to this bill and are made a part thereof.) 1 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED (If other than home or office) 33. PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE & PHONE # SIGNED DATE PIN# GRP# (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) WCC FORM # 14-A REV. DATE 5/95 PLEASE PRINT OR TYPE FORMHCFA-1500 (12-90)FORM OWCP-1500 FORM RRB- I 500