CMS-1500 UB-04 CMS-1450 Package free printable template

CARRIER HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA MEDICARE MEDICAID Medicare TRICARE CHAMPUS Sponsor s SSN Medicaid GROUP HEALTH PLAN SSN or ID CHAMPVA Member ID 3. AUTO ACCIDENT PLACE State c. OTHER ACCIDENT c. INSURANCE PLAN NAME OR PROGRAM NAME NO YES d. IS THERE ANOTHER HEALTH BENEFIT PLAN 10d. RESERVED FOR LOCAL USE READ BACK OF FORM BEFORE COMPLETING SIGNING THIS FORM. 12. PATIENT S OR AUTHORIZED PERSON S 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. PRIOR AUTHORIZATION NUMBER 24. A. BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS SEE SEPARATE INSTRUCTIONS ISSUED BY APPLICABLE PROGRAMS. NOTICE Any person who knowingly files a statement of claim containing any misrepresentation or any false incomplete or misleading information may be guilty of a...criminal act punishable under law and may be subject to civil penalties. REFERS TO GOVERNMENT PROGRAMS ONLY MEDICARE AND CHAMPUS PAYMENTS A patient s signature requests that payment be made and authorizes release of any information necessary to process the claim and certifies that the information provided in Blocks 1 through 12 is true accurate and complete. In the case of a Medicare claim the patient s signature authorizes any entity to release to Medicare medical and nonmedical information...including employment status and whether the person has employer group health insurance liability no-fault worker s compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made. 8. For Medicaid purposes The submitter understands that because payment and satisfaction of this claim will be from Federal and State funds any false statements documents or concealment of a material fact are subject to prosecution under applicable Federal or State...Laws. 9. For TRICARE Purposes complete to the best of the submitter s knowledge and belief and services were medically necessary and appropriate for the health of the patient b The patient has represented that by a reported residential address outside a military medical treatment facility catchment area he or she does not live within the catchment area of a U.S. military medical treatment facility or if the patient resides within a catchment area of such a facility a copy of Non-Availability...Statement DD Form 1251 is on file or the physician has certified to a medical emergency in any instance where a copy of a NonAvailability Statement is not on file c The patient or the patient s parent or guardian has responded directly to the provider s request to identify all health insurance coverage and that all such coverage is identified on the face of the claim except that coverage which is exclusively supplemental payments to TRICARE-determined benefits d The amount billed to TRICARE has...been billed after all such coverage have been billed and paid excluding Medicaid and the amount billed to TRICARE is that remaining claimed against TRICARE benefits e The beneficiary s cost share has not been waived by consent or failure to exercise generally accepted billing and collection efforts and f Any hospital-based physician under contract the cost of whose services are allocated in the charges included in this bill is not an employee or member of the Uniformed Services. For purposes of...this certification an employee of the Uniformed Services is an employee appointed in civil service refer to 5 USC 2105 including part-time or intermittent employees but excluding contract surgeons or other personal service contracts. 9. For TRICARE Purposes complete to the best of the submitter s knowledge and belief and services were medically necessary and appropriate for the health of the patient b The patient has represented that by a reported residential address outside a military medical...treatment facility catchment area he or she does not live within the catchment area of a U.S. military medical treatment facility or if the patient resides within a catchment area of such a facility a copy of Non-Availability Statement DD Form 1251 is on file or the physician has certified to a medical emergency in any instance where a copy of a NonAvailability Statement is not on file c The patient or the patient s parent or guardian has responded directly to the provider s request to identify...all health insurance coverage and that all such coverage is identified on the face of the claim except that coverage which is exclusively supplemental payments to TRICARE-determined benefits d The amount billed to TRICARE has been billed after all such coverage have been billed and paid excluding Medicaid and the amount billed to TRICARE is that remaining claimed against TRICARE benefits e The beneficiary s cost share has not been waived by consent or failure to exercise generally accepted...billing and collection efforts and f Any hospital-based physician under contract the cost of whose services are allocated in the charges included in this bill is not an employee or member of the Uniformed Services. For purposes of this certification an employee of the Uniformed Services is an employee appointed in civil service refer to 5 USC 2105 including part-time or intermittent employees but excluding contract surgeons or other personal service contracts. Similarly member of the Uniformed...Services does not apply to reserve g Based on 42 United States Code 1395cc a 1 j all providers participating in Medicare must also participate in TRICARE for inpatient hospital services provided pursuant to admissions to hospitals occurring on or after January 1 1987 and h If TRICARE benefits are to be paid in a participating status the submitter of this claim agrees to submit this claim to the appropriate TRICARE claims processor. The patient s signature on the provider s request to bill...Medicare medical and non-medical information including employment status and whether the person has employer group health insurance which is responsible to pay for the services for which this Medicare claim is made. 8. For Medicaid purposes The submitter understands that because payment and satisfaction of this claim will be from Federal and State funds any false statements documents or concealment of a material fact are subject to prosecution under applicable Federal or State Laws. 9. For...TRICARE Purposes complete to the best of the submitter s knowledge and belief and services were medically necessary and appropriate for the health of the patient b The patient has represented that by a reported residential address outside a military medical treatment facility catchment area he or she does not live within the catchment area of a U.S. military medical treatment facility or if the patient resides within a catchment area of such a facility a copy of Non-Availability Statement DD...Form 1251 is on file or the physician has certified to a medical emergency in any instance where a copy of a NonAvailability Statement is not on file c The patient or the patient s parent or guardian has responded directly to the provider s request to identify all health insurance coverage and that all such coverage is identified on the face of the claim except that coverage which is exclusively supplemental payments to TRICARE-determined benefits d The amount billed to TRICARE has been billed...after all such coverage have been billed and paid excluding Medicaid and the amount billed to TRICARE is that remaining claimed against TRICARE benefits e The beneficiary s cost share has not been waived by consent or failure to exercise generally accepted billing and collection efforts and f Any hospital-based physician under contract the cost of whose services are allocated in the charges included in this bill is not an employee or member of the Uniformed Services.