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CARRIER 1500 HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA MEDICARE MEDICAID (Medicare #) TRI CARE CAMPUS (Sponsor s SSN) (Medicaid #) GROUP HEALTH PLAN (SSN
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Red's date of birth is February 15, 1985.
Red is required to file their date of birth.
Red's date of birth can be filled out by providing their birth date in the required format.
The purpose of red's date of birth is to accurately identify them.
The information that must be reported on red's date of birth is their birth date.
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