of 2
Current View
OR SUPPLIES FURNISHED FOR EACH DATE GIVEN
PATIENT AND INSURED (SUBSCRIBER) INFORMATION
1. PATIENT'S NAME (LAST NAME, FIRST NAME, MIDDLE INITIAL) 2. PATIENT'S DATE OF BIRTH 3. SUBSCRIBER'S NAME (LAST NAME, FIRST NAME, MI
DDLE INITIAL)
4. PATIENT'S ADDRESS (STREET, CITY, STATE, ZIP CODE) 5. PATIENT'S SEX 6. SUBSCRIBER'S CERTIFICATE NO.
MALE
□□
FEMALE
7. PATIENT'S RELATIONSHIP TO INSURED 8. SUBSCRIBER'S GROUP NO.
RECIPROCITY
SELF SPOUSE CHILD OTHER
□ □ □ □
9. OTHER HEALTH INSURANCE (ENTER NAME AND ADDRESS OF
OTHER INSURANCE, POLICY HOLDER OF OTHER INSURANCE
AND POLICY HOLDER’S EMPLOYER.
10. WAS CONDITION RELATED TO 11. SUBSCRIBER'S ADDRESS (STREET, CITY, STATE, ZIP CODE)
A. PATIENT'S EMPLOYMENT
YES
□ □
NO
B. ACCIDENT
11A. CHAMPUS SPONSOR'S
AUTO
□ □
OTHER STATUS
□
ACTIVE
□
RETIRED BRANCH OF SERVICE
DUTY
□
DECEASED
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE
I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM.
SIGNED
DATE
PHYSICIAN OR SUPPLIER INFORMATION
14. DATE OF: ILLNESS (FIRST SYMPTOM) OR 15. DATE FIRST CONSULTED YOU 16. IF PATIENT HAS HAD SAME OR SIMILAR 16A. IF EME
RGENCY
INJURY (ACCIDENT) OR PREGNANCY FOR THIS COND
ITION I
LLNESS OR INJURY, GIVE DATES CHECK HERE
□
17. DATE PATIENT ABLE TO 18. DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY
RETURN TO WORK
FROM THROUGH FROM THROUGH
19. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE (E.G., PUBLIC HEALTH AGENCY) 20. FOR SERVI
CES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION DATES
ADMITTED DISCHARGED
21. NUMBER AND NAME OF FACILITY WHERE SERVICES RENDERED (IF OTHER THAN OFFICE) 22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFI
CE?
YES
□ □
NO CHARGES
23. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE NUMBERS B.
1,2,3 ETC. OR DX CODE
EPSDT YES
□□
NO
1.
FAMILY PLANNING YES
□□
NO
2.
3.
PRIOR
4.
AUTHORIZATION NO.
24. A B C FULLY DESCRIBE PROCEDURES, MEDICAL SERVICES OR SUPPLIES D E F G H
DATE OF SERVICE PLACE
OF PROCEDURE CODE DIAGNOSIS DAYS T.O.S
FROM TO SERVICE (IDENTIFY ) (
EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) CODE CHARGES OR UNITS
25. SIGNATURE OF PHYSICIAN OR SUPPLIER (INCLUDING DEGREE(S) OR 26. ACCEPT ASSIGNMENT (GOVERNMENT 27. TOTAL CHARGE 28. AMOUNT PAID 29. B
ALANCE DUE
CREDENTIALS) (I CERTIFY THAT THE STATEMENTS ON THE REVERSE CLAIMS ONLY)
APPLY TO THIS BILL AND ARE MADE A PARTY THEREOF)
YES
□ □
NO
30. YOUR SOCIAL SECURITY NO.
32. YOUR PATIENT'S ACCOUNT NO. 33. YOUR EMPLOYER ID NO.
N
31. PHYSICIAN, SUPPLIER AND/OR GROUP NAME, ADDRESS,
ZIP CODE AND TELEPHONE NO.
Z4294 R6/11
P.O. Box 6018
Cleveland, Ohio 44101-1018
VISION CARE
M
M
M

PATIENT AND INSURED (SUBSCRIBER) INFORMATION
1. PATIENT'S NAME (LAST NAME, FIRST NAME, MIDDLE INITIAL) 2. PATIENT'S DATE OF BIRTH 3.
SUBSCRIBER'S NAME (LAST NAME, FIRST NAME, MIDDLE INITIAL)
4. PATIENT'S ADDRESS (STREET, CITY, STATE, ZIP CODE) 5. PATIENT'S SEX 6. SUBSCRIBER'S CERTIFICATE NO.
MALE
□□
FEMALE
7. PATIENT'S RELATIONSHIP TO INSURED 8. SUBSCRIBER'S GROUP NO.
RECIPROCITY
SELF SPOUSE CHILD OTHER
□ □ □ □
9. OTHER HEALTH INSURANCE (ENTER NAME AND ADDRESS OF
OTHER INSURANCE, POLICY HOLDER OF OTHER INSURANCE
AND POLICY HOLDER’S EMPLOYER.
10. WAS CONDITION RELATED TO 11. SUBSCRIBER'S ADDRESS (STREET, CITY, STATE, ZIP CODE)
A. PATIENT'S EMPLOYMENT
YES
□ □
NO
B. ACCIDENT
11A. CHAMPUS SPONSOR'S
AUTO
□ □
OTHER STATUS
□
ACTIVE
□
RETIRED BRANCH OF SERVICE
DUTY
□
DECEASED
N
P.O. Box 6018
Cleveland, Ohio 44101-1018
VISION CARE
PLACE OF SERVICE CODES:
1 – Inpatient Hospital
2 – Outpatient Hospital
3 – Doctor's Office
4 – Patient's Home
5 – Day Care Facility (PSY)
6 – Night Care Facility (PSY)
7 – Nursing Home
8 – Skilled Nursing Facility
9 – Ambulance
0 – Other Locations
A – Independent Laboratory
B – Ambulatory Surgical Center
C – Residential Treatment Center
D – Specialized Treatment Facility
E – Comprehensive Outpatient
Rehabilitation Facility
F –
Independent Kidney Disease
Treatment Center
TYPE OF SERVICE CODES:
1 – Medical Care
2 – Surgery
3 – Consultation (Inpatient only)
4 – Diagnostic X-Ray
5 – Diagnostic Laboratory
6 – Radiation Therapy
7 – Anesthesia
8 – Assistant at Surgery
9 – Other Medical Service
0 – Blood or Packed Red Cells
A – Used DME
F – Ambulatory Surgical Center
H – Hospice
L – Renal Supplies in the Home
M – Alternate Payment for Maintenance Dialysis
N – Kidney Donor
V – Pneumococcal Vaccine
Y – Second Opinion on Elective Surgery
Z – Third Opinion on Elective Surgery
Signature of Physician (OR SUPPLIER): I certify that the services listed above were medically indicated and necessary to the he
alth of the patient and were
personally rendered by me or my employee under my personal direction.
NOTICE: This is to certify that the foregoing information is true, accurate and complete.
Rx
DOE, JOHN
Subscriber Name
123456789
Certificate Number
123ABC
Group Number
F 19 4.00/2.00 D 034 12-31-92
TypeChd AgeDed AmtAg CdDays SupplyExp Date
VISION CARE
P.O. Box 6018
Cleveland, Ohio 44101-1018