Drag fields from the Field List and drop them on the page.‎
(Medicare #)
(Medicaid#)
(Sponsor's SSN)(VA File #)(SSN or ID)(SSN)(ID)FM3. PATIENT'S BIRTHDATEOtherChildSpouseSelf6. PATIENT RELATIONSHIP TO INSURED1.  MEDICAREMEDICAIDCHAMPUSCHAMPVAGROUP
HEALTHPLANFECA
BLK LUNGOTHEROtherPart-Time
StudentMarriedFull-Time
StudentEmployedSingle8. PATIENT STATUSNOYESYESNONOYES10. IS PATIENT'S CONDITION RELATED TO:a. EMPLOYMENT? (CURRENT OR PREVIOUS)b. AUTO ACCIDENT?c. OTHER ACCIDENT?FMFMYESNOYESNOEINSSNNOYES2. PATIENT'S NAME Last Name, First Name, Middle Initial)5. PATIENT'S ADDRESS (No., Street)CITYZIP CODE9.  OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)a.  OTHER INSURED'S POLICY OR GROUP NUMBERb.  OTHER INSURED'S DATE OF BIRTHc.  EMPLOYER'S NAME OR SCHOOL NAMEd.  INSURANCE PLAN NAME OR PROGRAM NAME10d.  RESERVED FOR LOCAL USE1a.  INSURED'S I.D. NUMBER                         (FOR PROGRAM IN ITEM 1)4.  INSURED'S NAME (Last Name, First Name, Middle Initial)7.  INSURED'S ADDRESS ( No., Street)CITYZIP CODE11.  INSURED'S POLICY GROUP OR FECA NUMBERa.  INSURED'S DATE OF BIRTHb.  EMPLOYER'S NAME OR SCHOOL NAMEc.  INSURANCE PLAN NAME OR PROGRAM NAMEd.  IS THERE ANOTHER HEALTH BENEFIT PLAN?If yes,  return to and complete item 9 a-dSIGNED
DATE
12.  PATIENT'S OR AUTHORIZED PERSONS 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 PAGE 2 BEFORE COMPLETING AND SIGNING THIS FORM.SIGNED
13.  INSURED'S OR AUTHORIZED PERSON'S SIGNATURE. I authorize
payment of medical benefits to the undersigned physician or supplier for
services described below.14.  DATE OF CURRENT:15.  IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS,
GIVE FIRST DATE.FROMTO16.  DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE17a.  I.D. NUMBER OF REFERRING PHYSICIAN19.  RESERVED FOR LOCAL USEFROMTO18.  HOSPITALIZATION DATES RELATED TO CURRENT SERVICES$ CHARGES20.  OUTSIDE LAB?22.  MEDICAID RESUBMISSION
CODEORIGINAL REF. NO.23.  PRIOR AUTHORIZATION NUMBER
1.2.
3.
4.
21.  DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3,OR 4 TO ITEM 24E BY LINE)25.  FEDERAL TAX I.D. NUMBER26.  PATIENT'S ACCOUNT NO.27.  ACCEPT ASSIGNMENT?28.  TOTAL CHARGE29.  AMOUNT PAID30.  BALANCE DUE31.  SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on Page 2
apply to this bill and are made a part thereof.)SIGNED DATE32.  NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
RENDERED (If other than home or office)NO., STREET:CITY, ST, ZIP:NAME:NAME:NO., STREET:CITY, ST, ZIP:33.  PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, & PHONE # PIN#STATETELEPHONE (Include Area Code)STATETELEPHONE (Include Area Code)ILLNESS (First Symptom) OR
INJURY (Accident) OR
PREGNANCY (LMP)
PICAPICAHEALTH INSURANCE CLAIM FORMPLEASE
DO NOT
STAPLE
IN THIS
AREAFORM HCFA-1500 - MassageBiz.NET24.ABCDEFGHIJKDATE(S) OF SERVICEFromToPlace
of
ServiceType
of
ServicePROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)CPT/HCPCSMODIFIERDIAGNOSIS
CODE$ CHARGESDAYS
OR
UNITSEPSDT
Family
PlanEMGCOBRESERVED FOR
LOCAL USE
PLACE (State)