Professional legal forms

Shelter care claim form ShelterCare Claim Form www.sheltercare.com 1-877-707-7297 CHECkLIst NOTE: You must submit an itemized paid invoice with claim form. Please return the completed claim form with paid invoices and complete

Eyemed claim form Out-Of-Network Claim Form Most EyeMed Vision Care plans allow members the choice to visit an in-network or out-of-network vision care provider. Com EyeMed Vision Care Attn OON Claims P. O. Box 8504 Mason OH 45040-7111 Print Reset Fraud Warning Statements Arizona For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. If you choose an out-of-network provider please complete the following steps prior to submitting the claim form to EyeMed. Any missing or incomplete information may result in delay of payment or the form being returned. Please complete and send this form to EyeMed within 1 year from the original date of service at the out-of-network provider s office. 3. EyeMed will only accept itemized paid receipts that indicate the services provided and the amount charged for each service. The services must be paid in full in order to receive benefits. Handwritten receipts must be on the provider s letterhead. Attach itemized paid receipts from your provider to the claim form. If the paid receipt is not in US dollars please identify the currency in which the receipt was paid. 4. If it is later determined that the patient was not entitled to the reimbursement you agree to refund EyeMed in full. Please indicate to whom the reimbursement should be sent Subscriber Patient Sign the claim form where indicated. Date of Service Patient Information Last Name First Name MI Street Address City State Zip Phone Birth Date Plan Information Last First Plan Name Subscriber ID Request For Reimbursement Please Enter Amount Charged. Remember to include itemized paid receipts Exam Frames Lenses Contact Lenses includes fit and follow-up please submit all contact related charges at the same time If lenses were purchased please select type Single Bifocal Trifocal Progressive I hereby understand that without prior authorization form EyeMed Vision Care LLC for services rendered I may be denied reimbursement for submitted vision care services for which I am not eligible. EyeMed will reimburse you for authorized services according to your plan design. 2. Please complete all sections of this form to ensure proper benefit allocation. Plan information may be found on your benefit ID Card or via your human resources department. You only need to complete this form if you are visiting a provider that is not a participating provider on the EyeMed network. Not all plans have out-of-network benefits so please consult your member benefits information to ensure coverage of services and/or materials from non-participating providers. 1. When visiting an out-of-network provider you are responsible for payment of services and/or materials at the time of service. 3. EyeMed will only accept itemized paid receipts that indicate the services provided and the amount charged for each service. The services must be paid in full in order to receive benefits. Handwritten receipts must be on the provider s letterhead* Attach itemized paid receipts from your provider to the claim form* If the paid receipt is not in US dollars please identify the currency in which the receipt was paid* 4.

Sun lifeca pshcp form Public Service Health Care Plan (PSHCP) Claim Form Out-of-Country Claims (Comprehensive Coverage) The PSHCP is administered by Sun Life Assurance Companie of Canada, a member of the Sun Life Financial

Claim form for claim against c... CLAIM AGAINST THE COUNTY OF STANISLAUS (Government Code Section 910.et seq.) Claimants: Name SSN# Date of Birth Address Phone Number Name, address and phone number of person to receive notices concerning

Orange county ca fillable smal... SMALL CLAIMS BOOKLET HOW TO FILE AND SERVE A SMALL CLAIMS CASE SUPERIOR COURT OF CALIFORNIA COUNTY OF ORANGE To open a Small Claims Case, refer to and fill out the following: Information for Plaintiff

04 form NUBC National Uniform Billing Committee LIC9213257 QUAL FIRST THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. Green Required/Preferred Black Situational/Required if Applicable/Reserved 80 REMARKS H Q SAMPLE OUTPATIENT UB-04 FORM. New UB-04 Form Instructions The Office of Management and Budget OMB and the National Uniform Billing Committee NUBC previously approved the UB-04 claim form also known as the CMS-1450 form. The UB-04 claim form accommodates the National Provider Identifier NPI and incorporated other important changes. SAMPLE INPATIENT UB-04 FORM 3a PAT. CNTL b. MED. REC. 5 FED. TAX NO. 8 PATIENT NAME 9 PATIENT ADDRESS a 11 SEX OCCURRENCE CODE DATE c ADMISSION 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT TYPE OF BILL STATEMENT COVERS PERIOD FROM THROUGH b 10 BIRTHDATE CONDITION CODES d e 29 ACDT 30 STATE VALUE CODES AMOUNT 42 REV. The UB-04 form has been used exclusively for institutional billing beginning May 23 2007. Sample UB-04 forms for inpatient and outpatient services are enclosed. The UB-04 Claim Form and NPI NPI you must continue to report your current provider identification numbers in the appropriate areas of the form. UB-04 Data Field Requirements FIELD LOCATION UB-04 DESCRIPTION INPATIENT OUTPATIENT Provider Name and Address Required Pay-To Name and Address Situational 3a Patient Control Number 3b Medical Record Number Type of Bill Federal Tax Number Statement Covers Period Future Use N/A 8a Patient ID 8b Patient Name Patient Address Patient Birthdate Patient Sex Admission Date Admission Hour Type of Admission/Visit Source of Admission Discharge Hour Patient Discharge Status 18-28 Condition Codes Required if Applicable Accident State 31-34 Occurrence Code and Dates 35-36 Occurrence Span Codes and Dates Subscriber Name and Address 39-41 Value Codes and Amounts Revenue Code HCPCS/Rates For additional information on the completion of fields please refer to the NUBC Official UB-04 Data Specifications Manual. 2012 PASSPORT HEALTH PLAN PA-111378 Service Date Units of Service Total Charges By Rev. Code Non-Covered Charges Payer Identification Name NPI Release of Info Certification Assignment of Benefit Certification Prior Payments Estimated Amount Due Health Plan IDs Insured s Name Patient s Relation to the Insured Insured s Unique ID Insured Group Name Treatment Authorization Codes Document Control Number Employer Name Diagnosis/Procedure Code Qualifier Principal Diagnosis Code/Other Diagnosis Codes Admitting Diagnosis Code Patient s Reason for Visit Code PPS Code External Cause of Injury Code Principal Procedure Code/Date Attending Name/ ID-Qualifier Operating ID 78-79 Other ID Remarks Code-Code Field/Qualifiers 0-A0 A1-A4 A5-B0 B1-B2 B3 We would also like to remind you of the requirements for electronic transactions. As a reminder Passport Health Plan strongly recommends the continued use of plan identification numbers in addition to NPI. This form replaced the UB-92 claim form and was phased in over a transition period beginning March 1 2007. The UB-04 form has been used exclusively for institutional billing beginning May 23 2007. Sample UB-04 forms for inpatient and outpatient services are enclosed. The UB-04 Claim Form and NPI NPI you must continue to report your current provider identification numbers in the appropriate areas of the form. UB-04 Data Field Requirements FIELD LOCATION UB-04 DESCRIPTION INPATIENT OUTPATIENT Provider Name and Address Required Pay-To Name and Address Situational 3a Patient Control Number 3b Medical Record Number Type of Bill Federal Tax Number Statement Covers Period Future Use N/A 8a Patient ID 8b Patient Name Patient Address Patient Birthdate Patient Sex Admission Date Admission Hour Type of Admission/Visit Source of Admission Discharge Hour Patient Discharge Status 18-28 Condition Codes Required if Applicable Accident State 31-34 Occurrence Code and Dates 35-36 Occurrence Span Codes and Dates Subscriber Name and Address 39-41 Value Codes and Amounts Revenue Code HCPCS/Rates For additional information on the completion of fields please refer to the NUBC Official UB-04 Data Specifications Manual. 2012 PASSPORT HEALTH PLAN PA-111378 Service Date Units of Service Total Charges By Rev. Code Non-Covered Charges Payer Identification Name NPI Release of Info Certification Assignment of Benefit Certification Prior Payments Estimated Amount Due Health Plan IDs Insured s Name Patient s Relation to the Insured Insured s Unique ID Insured Group Name Treatment Authorization Codes Document Control Number Employer Name Diagnosis/Procedure Code Qualifier Principal Diagnosis Code/Other Diagnosis Codes Admitting Diagnosis Code Patient s Reason for Visit Code PPS Code External Cause of Injury Code Principal Procedure Code/Date Attending Name/ ID-Qualifier Operating ID 78-79 Other ID Remarks Code-Code Field/Qualifiers 0-A0 A1-A4 A5-B0 B1-B2 B3 We would also like to remind you of the requirements for electronic transactions.

Claim lincoln form 2011 2019 Mail Completed Claims to The Lincoln National Life Insurance Company Dental Claims Processing Center PO Box 614008 Orlando FL 32861 Toll Free 800-423-2765 FAX 877-843-3945 DENTAL CLAIM FORM HEADER INFORMATION 1. Type of Transaction Check all applicable boxes h Statement of Actual Services h Request for Predetermination/Preauthorization h EPSDT / Title XIX 2. Predetermination/Preauthorization Number POLICYHOLDER / SUBSCRIBER INFORMATION INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION 12. Policyholder/Subscriber Name Last First Middle Initial Suffix Address City State ZIP For Insurance Company Named in 3 3. Company/Plan Name Address City State ZIP 13. Date of Birth MM/DD/CCYY 14. Gender hM hF OTHER COVERAGE 4. Other Dental or Medical Coverage h No Skip 5-11 h Yes Complete 5-11 16. Plan/Group Number 17. Employer Name 5. Name of Policyholder/Subscriber in 4 Last First Middle Initial Suffix PATIENT INFORMATION 19. Student Status h Self h Spouse h Dependent Child h Other h FTS h PTS 10. Patient s Relationship to Person Named in 5 20. Name Last First Middle Initial Suffix Address City State ZIP 11. Other Insurance Company/Dental Benefit Plan Name Address City State ZIP RECORD OF SERVICES PROVIDED 24. Procedure Date MM/DD/CCYY 25. Area of Oral Cavity 26. Tooth System 27. Tooth Number s 28. Tooth or Letter s Surface Code 30. Description 31. Fee MISSING TEETH INFORMATION 34. Place an X on each missing tooth Permanent Primary 2 3 4 5 6 7 8 10 11 12 13 14 15 16 A B C D E F G H I J 2 31 30 29 28 27 26 25 4 23 22 21 20 19 18 17 T S R Q P O N M L K 32. Other Fee s 33. Total Fee 35. Remarks AUTHORIZATIONS ANCILLARY CLAIM/TREATMENT INFORMATION 36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan unless prohibited by law or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim* 38. Place of Treatment Check applicable box 39. Number of Enclosures 00 to 99 h Provider s Office h Hospital h ECF h Other Radiograph s Oral Image s Model s h 40. Is Treatment for Orthodontics 41. Date Appliance Placed MM/DD/CCYY h No Skip 41-42 h Yes Complete 41-42 42. Months of Treatment 43. Replacement of Prosthesis 44. Date Prior Placement Remaining h No h Yes Complete 44 X Patient/Guardian Signature Date 37. I hereby authorize and direct payment of the dental benefits otherwise payable to me directly to the below named dentist or dental entity. 45. Treatment Resulting from Check applicable box h Occupational illness/injury h Auto accident h Other accident 47. Auto Accident State 46. Date of Accident MM/DD/CCYY TREATING DENTIST AND TREATMENT LOCATION Subscriber Signature 53. I hereby certify that the procedures as indicated by date are in progress for procedures that require multiple visits or have been completed and that the fees submitted are the actual BILLING DENTIST OR DENTAL ENTITY Leave blank if dentist or dental entity fees I have charged and intend to collect for those procedures.

Ada dental claim form Adacatalog. org Comprehensive completion instructions for the ADA Dental Claim Form are found in Section 4 of the ADA Publication titled CDT-2007/2008. Wpc-edi. com/codes/taxonomy Should there be any updates to ADA Dental Claim Form completion instructions the updates will be posted on the ADA s web site at www. Name Address City State Zip Code 18. Relationship to Policyholder/Subscriber in 12 Above J400 Same as ADA Dental Claim Form J401 J402 J403 J404 To Reorder call 1-800-947-4746 or go online at www. Five relevant extracts from that section follow GENERAL INSTRUCTIONS A. The form is designed so that the name and address Item 3 of the third-party payer receiving the claim insurance company/dental benefit plan is visible in a standard 10 window envelope. Please fold the form using the tick-marks printed in the margin. B. In the upper-right of the form a blank space is provided for the convenience of the payer or insurance company to allow the assignment of a claim or control number. C. All Items in the form must be completed unless it is noted on the form or in the following instructions that completion is not required. D. Dental Claim Form HEADER INFORMATION 1. Type of Transaction Mark all applicable boxes Statement of Actual Services Request for Predetermination / Preauthorization EPSDT/ Title XIX POLICYHOLDER/SUBSCRIBER INFORMATION For Insurance Company Named in 3 2. Predetermination / Preauthorization Number 12. Policyholder/Subscriber Name Last First Middle Initial Suffix Address City State Zip Code INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION 3. Company/Plan Name Address City State Zip Code 14. Gender 13. Date of Birth MM/DD/CCYY M OTHER COVERAGE 16. Plan/Group Number 4. Other Dental or Medical Coverage F 17. Employer Name Yes Complete 5-11 No Skip 5-11 PATIENT INFORMATION 5. Name of Policyholder/Subscriber in 4 Last First Middle Initial Suffix Self Spouse Dependent Other 11. Other Insurance Company/Dental Benefit Plan Name Address City State Zip Code 22. Gender RECORD OF SERVICES PROVIDED 25. Area 26. of Oral Tooth Cavity System 28. Tooth Surface 27. Tooth Number s or Letter s 29. Procedure Code MISSING TEETH INFORMATION Permanent A B C D E G H I J 32. Other Fee s T S R Q P O N L K 33. Total Fee fold Primary 31. Fee Sa 34. Place an X on each missing tooth 30. Description m PTS 23. Patient ID/Account Assigned by Dentist FTS pl MM/DD/CCYY 19. Student Status Dependent Child 20. Name Last First Middle Initial Suffix Address City State Zip Code 10. Patient s Relationship to Person Named in 5 e 35. Remarks AUTHORIZATIONS ANCILLARY CLAIM/TREATMENT INFORMATION 36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan unless prohibited by law or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim* 38.

2017 ada dental claim form HEADER INFORMATION Dental Claim Form Request for Predetermination / Preauthorization 1. Type of Transaction (Mark all applicable boxes) Statement of Actual Services EPSDT/ Title XIX 2. Predetermination

Universal claim form CARDHOLDER NAME L/F/MI 1A4 PLAN NAME OTHER COVERAGE CODE (1) PATIENT NAME L/F/MI PERSON CODE (2) PATIENT (4) RELATIONSHIP CODE FOR OFFICE USE ONLY 1842 - 1108 - 9227M CARDHOLDER I.D. GROUP I.D. Copyright

Cigna dental insurance claim f... Dental Claim Form HEADER INFORMATION 1. Type of Transaction (Mark all applicable boxes) Statement of Actual Services EPSDT/ Title XIX 2. Predetermination / Preauthorization Number Request for Predetermination

Petition small claims form This DESIGNATION OF REPRESENTATIVE TO FILE PETITION as petitioner or officer thereof hereby designate I to act as my representative in any and all proceedings before the Small Claims Assessment Review of the Supreme Court in the assessment of my real property as it appears on the County for purposes of reviewing year assessment roll of Signature of Owner Or officer thereof Date PART V ELIGIBILITY AND CERTIFICATION I certify that d e f The owner has previously filed a complaint required for administrative review of assessments. UCS 900 Rev. March 2007 PETITION SMALL CLAIMS ASSESSMENT REVIEW IN COUNTIES OUTSIDE NEW YORK CITY one petition per parcel RPTL 730 PART 1 GENERAL INFORMATION SUPREME COURT COUNTY OF Filing Calendar Assessing Unit Date of final completion and filing of assessment roll a Total b Exempt amount c Taxable assessed value 3a-3b Date of filing or mailing petition Name of owner or owners of property Post Office Address Telephone If applicable name and address of representative of owner if representative is filing application Owner must complete Designation of Representative section. Description of property as it appears on the assessment roll. Tax Map Section Block Lot Location of property street road highway number and city town or village PART II GROUNDS FOR PETITION A. Assessment requested on the complaint form filed with the Board of Assessment Review B. Total assessment CALCULATION OF EQUALIZED VALUE AND MAXIMUM REDUCTION IN ASSESSMENT Property is NOT in a special assessing unit. ASSESSED VALUE C. EQUALIZATION RATE EQUALIZED VALUE Property IS in a special assessing unit. CLASS ONE RATIO If the EQUALIZED VALUE exceeds 450 000 enter the ASSESSED VALUE here Multiply the ASSESSED VALUE by Enter the result here The result is the maximum total assessment request reduction allowable. x. 25 UNEQUAL ASSESSMENT The total assessment is unequal because the property is assessed at a higher percentage of full market value than check one. a the average of all other property on the assessment roll or b the average of residential property on the assessment roll* Full market value of property Based on one or more of the following petitioner believes this property should be assessed at of full market value The latest State equalization rate for the assessing unit in which the property is located enter latest equalization rate. The latest residential assessment ratio for the assessing unit in which the property is located enter residential assessment ratio A sample of market values of recent sales prices and assessments of comparable residential properties on which petitioner relies for objection list parcels on a separate sheet and attach. Statements of the assessor or other local official that property has been placed on the roll at. This amount may Petitioner believes the total assessment should be reduced to not be less than the total assessment amount indicated in Section A 1 or Section B 3 whichever is greater. D. EXCESSIVE ASSESSMENT The total assessed value exceeds the full market value of the property. Total assessed value of property Complainant believes the total assessment should be reduced to a full value of Attach list of parcels upon which complainant relies for objection if applicable.

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