AGING MARYLAND
HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA 1. MEDICARE MEDICAID TRICARE CHAMPUS (Sponsor's SSN) CHAMPVA GROUP HEALTH PLAN (SSN or ID) FECA BLK LUNG (SSN) SEX M 5. PATIENT'S ADDRESS (No., Street) F 7. INSURED'S ADDRESS (No., Street) OTHER 1a. INSURED'S I.D. NUMBER PICA (For Program in Item 1) (Medicare #) (Medicaid #) (Member ID#) (ID) 4. INSURED'S NAME (Last Name, First Name, Middle Initial) 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3 MoreINSURED'S NAME (Last Name, First Name, Middle Initial). 7. INSURED'S ADDRESS (No. ..... DO NOT MAIL COMPLETED CLAIM FORMS TO THIS ADDRESS. Less
Not the form you were looking for?
Upload form
Not the form you were looking for?
Upload form
Please wait while form is uploaded and processed.
After you finish filling the form, you can Print, Email or Export your form. |
|