01490-GBE_EN_PanB_Clsim Guide 2013-10-25 ———— DemTVENT oF Hea mo awn somes Form aronovea —= rr anne 8 es PATIENT'S REQUEST FOR MEDICAL PAYMENT TMPORTANT - SEE OTHER SIDE FOR INSTRUCTIONS [PLEASE TYPE OR PANT NFORMATION MEDICAL NSURANCE BENEFITS SOCIAL SECURITY ACT NOTICE: Amon who mioposrs rakes ssn nirmaionequeed bythe rm may don comicten be set fe and npsonnet under ‘Foden on Pat 8 Medcae bees on pre eres an eqed yong wa retin (0 CFR 210) Name of Beneficiary fam Heath inewrance Cod ‘SEND COMPLETED FORM TO: oa om ono ‘eur Medea carer Myouneed nei ct S00MEDICARE 1 (veooe. <2 iam Narber fom oath insurance Cad Paes Sax 2 O Mate Female - Patents Mating Aaaress (Oy Sate, Zp Code) "Tuphone Nonar [check nee hss anew adéress ia 3 Fina FRE RATT a0 ~~ oH (_— i Dosa he es oF RR WA paar TaN Wea ‘meee ee A Paint ptoyreat 40] Ces No . 8 Acctent lato Comer spate bang vested wth ge)tOr lays or oy Vansant? Ove One 2: Are you erpoyed and covered under an enqayee heath plan? Ove Ne bs your spouse employed and ao you covereé under your spouses empoyee neath pan? Owes Ne |e fyou nave any medal coverage ater than Maseare, suchas pre nsurance, employment restos haurance, ‘State Agency (Medical), or the VA, complete: [Name and Address of othr insurance, tate Agency (Medicaid, orVA office oe Ploy or WeiealAssisanoe No Not: if you D0 NOT want payment informator on tis claim oloased, put an (X) here C1 [I ITHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE 10 THE SOCIAL SECURITY AOMENISTRATION —— lano CENTERS FOR MEDICARE & UEDICAD SERVICES OR ITs WTERMEEDIARIES OR CARMIERS ANY INFORMATION NEEDED FOR THIS OR A IRELATED MEDICARE-CLAM, | PERMAT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL, AND REQUEST PAYMENT [OF MEDICAL INSURANGE BENEFITS TOME. Signature of Pationt (patient is unable to sign, sue Block 6 on reveso) Date signed 6 eb TRPORTANT. ATTACH ITEMIZED BILLS FROMYOUR DOCTOR{S) OR SUPPLIER(S) TO THE BACK OF THIS FORM. "Far CE TaROS S) (TIS) EF O0501490-GBE_EN_PartB_Claim Guide 2013-10-25 HOW TO FILL OUT THIS MEDICARE FORM Medicare wil ey you deaty we you complet hs fom and sth an enzo lon you dover mpl Your il done ot av be pi fie you sit ‘his din or py bu gee MUST sch on eld in exe Medi prose se. Mal yu camped cn om oth Maton Car rape {er possng your im. Iya do nt oo he adres of oa oer eal 1-800 VEDICARE (-800403-07), FOLLOW THESE INSTRUCTIONS CAREFULLY: ‘A. Completion of his frm. Block 1. Pret your ume shown en jour Meicre Cul (Last Nene, Fat Nee, Mids Nan), ‘Block 2. hn your Health insane Cli Number icing Gh eter he ead exeety eit shown on your Median ced. (Ghat he propia box fre pte oe ‘Block 3. Fei jour mang adres nd inl your phone umber ia Block 3. Block 4 Desi hile rinjury fr which ou reve weet Chek te spore oxo Blocks had 4, Blok se. Canplate it Block fy we ag 6S aol enrolled i hel inane plan where you are caret wating. Blok sb. Compete is Blckfyou ag 65 ede en alle in bea irene pen whee your eu is urey worl. Block 5. Complete is Bloc you ave ny metic coverage er han Moder. Be srt provide he Poi eMail Aaitane Numb You may chock the ‘ox provided i'yudo ot Nah payne! afomaton fom is cm reese a your ober re ‘Bloc 6. Desa sign your sume Ifyou cane write your ame ike a X) ma Then ave wines sg irr ame a drt in Blok 610. yu ee competing ths fr fr nator Mee patio you sold weit BY) ad slg our une nd eden lock 6 You ak sold sow poo eeonsip pte an rly exp ye pale eros Blok 6b. Pint te dt you completed soem. ‘Each emized Bl MUST shoal of he allowing informatio + Date ca ence + es of ech sve ‘ecto Offs Independent Laberacry Ospina Ning Hone Pia’s Hone np + Descriptio of ach me or mec seve orgy fica, 1 Cope fo EACH savin + Dacar or spl’ me ad srs. Many ins bill how tense of sve dacts spp. TS VERY IMPORTANT THE ONE WHO TREATED ‘YOU BEIDENTIFED. Spl cite hisher nae o heb lg te genial sho om he yan’ Bl. Io, be sr you hve compl Ble 4 i fo + Mart any sve ca he il) ona aching fr nich you av sendy filo Medi in. + tft pts dessa plome cont yor Sai Seri fie formers on hwo ea ein, + Anwch on Exhnstn of Medire Beets nts fom fe ter inter ion ae li reqnning Moire pat COLLECTION AND USE OF MEDICARE INFORMATION We are authorized by the Centers for Medicare & Medicaid Services to ask you for infomation needed in the administration of the Medicare ‘program, Authority to collect information iin section 208(), 1872 and 1875 ofthe Social Security Act, as amended, ‘The information we obtain fo complete your Medicare claim is used to identify you and to determine your eligi i he services and supplies you received are covered by Medicare and to insure tht proper payment is made. Wy. Tis also used to decide ‘The information may also be given o other providers of services, caricrs, intermediaries, medical review boards, and other organizations 3s, ‘necessary to administer the Medicare program. For example, it may be necessary 1 disclose information to a hospital or doctor about the ‘Medicare benefits you have used ‘With one exception, which i discussed below, there are no penalties under Socal Security law or refusing to supply information. However, failre to Furnish information regarding the medical services rendered orth amount charged would prevent payment of the claim, Failure to furnish any other information, such as name or claim number, would delay payment ofthe clan {tis mandatory that you el us you are being treated fora work related inuy so we can determine whether worker's compensation will pay forthe treatment. Section 1877(a)3) ofthe Social Security Act provides criminal penalties for withholding this information. ci tee ei at 195 en we en a apn tn mon ae agl l OD cutl ae TlORD eel ae ‘Sota lings or fame epee ern en eno eg ota rope anger me eng dou ue se cane ne ein een ese an ent emai ay ene ence) gp Et Fe Oe ATL COMPLETED ELAIN FORMS TO THIS ADDRESS,(01490-0BE EN ParB Clim. Golde 2013-1025 Use the following address table to ensure the correct address will be provided on the claim. lif you live in: [Return your form to: Alabama [Cahaba GBA IMedicare Part B Claims IP.O. Box 6169 |Indianapolis, IN 46206 Alaska |American Samoa |Arkansas [Noridian Healthcare Solutions P.O. Box 6703 Fargo, ND 58108-6703 Noridian Healthcare Solutions P.O. Box 6777 Fargo, ND 58108-6777 INovitas Solutions P.O. Box 3098 |Mechanicsburg, PA 17055-1816 |Arizona \Noridian Healthcare Solutions P.O. Box 6704 |Fargo, ND 58108-6704 [California (Northern) [Noridian Healthcare Solutions IP.O. Box 6774 [Fargo, ND 58108-6774 |California (Southern) [Noridian Healthcare Solutions P.O. Box 6775 largo, ND 58108-6775 |Colorado |Novitas Solutions |P.O. Box 3107 Mechanicsburg, PA 17055-1823 {Connecticut National Government Services, Inc. P.O. Box 6178 Indianapolis, IN 46206-6178 |Delaware Novitas Solutions P.O. Box 3397 Mechanicsburg, PA 17055-1842 (District of Columbia (Washington DC) Novitas Solutions P.O. Box 3396 |Mechanicsburg, PA 17055-184101490-GBE_EN_PartB_Claim_ Guide 2013-1025 Florida First Coast Service Options, Inc. P.O. Box 2525 Jacksonville, FL 32231-0019 IGeorgia |Cahaba GBA Medicare Part B Claims P.O. Box 6169 Indianapolis, IN 46206 Noridian Healthcare Solutions P.O. Box 6777 Fargo, ND 58108-6777 |Hawaii Noridian Healthcare Solutions P.O. Box 6777 Fargo, ND 58108-6777 Idaho Noridian Healthcare Solutions |P.O. Box 6701 Fargo, ND 58108-6701 \Illinois National Government Services, Inc. P.O. Box 6475 Indianapolis, IN 46206-6475 \Indiana Wisconsin Physicians Service P.O. Box 8940 Madison, WI 53708-8940 lowa Wisconsin Physicians Service P.O. Box 8550 Madison, WI 53708-8550 |Kansas Wisconsin Physicians Service IP.O. Box 7238 Madison, WI 53707-7238 Kentucky ICGS Administrators, LLC P.O. Box 20019 Nashville, TN 37202 |Louisiana [Novitas Solutions P.O. Box 3097 Mechanicsburg, PA 17055-1815 |Maine National Government Services, Inc. P.O. Box 6178 Indianapolis, IN 46206-617801490.0BE,EN Pant. Chim_Guide 2013-10-25 [Maryland |Novitas Solutions |P.O. Box 3398 Mechanicsburg, PA 17055-1843 |Massachusetts National Government Services, Inc. P.O. Box 6178 Indianapolis, IN 46206-6178 [Michigan Wisconsin Physicians Service P.O. Box 8987 |Madison, WI 53708-8987 Minnesota Indianapolis, IN 46206-6475 Mississippi |National Government Services, Inc. |P.O. Box 6475 Novitas Solutions P.O. Box 3129 Mechanicsburg, PA 17055-1834 |Missouri Wisconsin Physicians Service P.O. Box 14260 |Madison, WI 53708-0260 =—= — —= = — = = == = [Montana \Noridian Healthcare Solutions P.O, Box 6735 |Fargo, ND 58108-6735 Nebraska Wisconsin Physicians Service P.O, Box 8667 |Madison, WI 53708-8667 \Nevada |Noridian Healthcare Solutions P.O. Box 6776 Fargo, ND 58108-6776 INew Hampshire National Government Services, Inc. P.O. Box 6178 Indianapolis, IN 46206-6178 INew Jersey Novitas Solutions P.O. Box 3030 Mechanicsburg, PA 17055-1802 |New Mexico Novitas Solutions P.O. Box 3107 Mechanicsburg, PA 17055-1823 New York National Government Services, Inc. |P.O. Box 6178 Indianapolis, IN 46206-617801490-GBE_EN_PantB_Claim Guide 2013-1025 |North Carolina [Palmetto GBA — J11 MAC Mail Code: AG-600 P.O. Box 100190 |Columbia, SC 29202-3190 |North Dakota \Noridian Healthcare Solutions P.O. Box 6706. Fargo, ND 58108-6706 \Northern Mariana Islands Noridian Healthcare Solutions P.O. Box 6777 Fargo, ND 58108-6777 |Ohio ICGS Administrators, LLC P.O. Box 20019 Nashville, TN 37202 |Oklahoma Novitas Solutions P.O. Box 3107 Mechanicsburg, PA 17055-1823 [Oregon INoridian Healthcare Solutions P.O. Box 6702 Fargo, ND 58108-6702 [Pennsylvania Novitas Solutions P.O. Box 3418 Mechanicsburg, PA 17055-1854 |Puerto Rico First Coast Service Options, Inc P.O. Box 45036 Jacksonville, FL 32231-5036 Rhode Island |National Government Services, Inc. P.O. Box 6178 Indianapolis, IN 46206-6178 South Carolina \Palmetto GBA — J11 MAC. |Mail Code: AG-600 P.O. Box 100190 |Columbia, SC 29202-3190 South Dakota |Noridian Healthcare Solutions IP.O. Box 6707 |Fargo, ND 58108-6707 \Tennessee \Cahaba GBA |Medicare Part B Claims P.O. Box 6169 Indianapolis, IN 46206(0{490-GBE_EN_PartB_Claim_Guide 2013-1025 \Texas |Novitas Solutions P.O. Box 3108 |Mechanicsburg, PA 17055-1824 [Utah |Noridian Healthcare Solutions P.O. Box 6725 Fargo, ND 58108-6725 |Vermont [National Government Services, Inc. P.O. Box 6178 {Indianapolis, IN 46206-6178 Virginia (Arlington and Fairfax Counties _ |Novitas Solutions including city of Alexandria) |P.O. Box 3396 Mechanicsburg, PA 17055-1841 | Virginia (The rest of the state.) Palmetto GBA — J11 MAC |Mail Code: AG-600 P.O. Box 100190 Columbia, SC 29202-3190 |Virgin Islands First Coast Service Options, Inc P.O. Box 45098 Jacksonville, FL 32231-5098 Washington Noridian Healthcare Solutions |P.O. Box 6700 |Fargo, ND 58108-6700 CEE West Virginia \Palmetto GBA — J11 MAC Mail Code: AG-600 P.O. Box 100190 |Columbia, SC 29202-3190 |Wisconsin National Government Services, Inc. P.O. Box 6475 Indianapolis, IN 46206-6475 Wyoming Noridian Healthcare Solutions P.O. Box 6708 Fargo, ND 58108-6708