Commercial

Insurance

Block
1
1a

x - other for ind/family plan

x - group plan

BCBS

Medicare
x in Medicare box

Medicaid
x in Medicaid box

Pt's name LAST, FIRST, MI

Pt DOB: MM DD YYYY: X box

appropriate for Gender

Policy holders: LAST, FIRST, MI

Pt Mailing Address 7 Phone

number

X for Pt relationship to policy

holder

leave blank

leave blank

7
8

Policy holders mailing address

and phone number
leave blank

leave blank
leave blank

leave blank
leave blank

completed only with secondary

9, 9a, 9d insurance
9b-9c
leave blank

11c

x in Tricare/champus

ID #

10a-c
10d
11
11a
11b

Tricare

x for pt conditions is related to

accident: work, auto, etc
leave blank
policy holder group ID #
policy holder dob
leave blank
name of policy holders
commercial health plan

leave blank

leave blank
leave blank

if dd form 2527 is attache

enter NONE
leave blank

leave blank
leave blank

leave blank
leave blank
leave blank

leave blank

leave blank

11d
12
13

x in no if there is no secondary
insurance
signature on file
signature on file
leave blank

14

MM DD YYYY of visit/symptoms

15

MM DD YYYY of prior episodes

16

MM DD YYYY time pt was not

able to work

17
17a
17b

first MI, credentials of referral

leave blank
NPI of referred provider

18
19
20
21
22

Admin date and discharge date

MM DD YYYY
leave blank
x for no: outside lab
ICD-10 codes up to 12
leave blank

23
24
24b
24c

prior authorization or referral #

procedure from MM DD YY
pos 2 digit code
leave blank

24d

cpt or hcpcs ii code with

modifier if applies

24e

diagnosis pointer from black

21

24f

fee charged for each service

24g

number of days for the service

leave blank

leave blank
leave blank

leave blank

24i
24j
25

leave blank
10 digits npi
ein or ssn for provider

26

pt account # assigned by
provider

27

x for yes: accepts assignment

28
29-30

total chargers for

services/procedures
leave blank

31

provider name and credential

32

name and address of service

and provider

32a
32b
33
33a
33b

10 digit npi as entered in block

32
leave blank
billing provider name and
addresss
10 digit npi of billing provider
leave blank

location name/address

Worker's Comp
x-other
employee ssn

name of patients employer

employer address

FECA number

is attached