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8SRevision:HCFAPM91 4(BPD)OMB No. 0938AUGlIST 1991State/Territory: SECTION 1 GENERAL PROVISIONS Citation7.142 CFR 430.12c)UAN Amendments The plan will be amended whenever necessary to reflect new
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hcfa-pm-91-4 is a form used for submitting healthcare claims for reimbursement.
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The purpose of hcfa-pm-91-4 is to request reimbursement from insurance companies for healthcare services provided.
Information such as patient name, date of birth, insurance information, diagnosis codes, and treatment codes must be reported on hcfa-pm-91-4.
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