DoL OWCP-1500 2012 free printable template

Print Form Reset Form CARRIER HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA MEDICAID TRICARE CHAMPUS GROUP CHAMPVA p Medicare p Medicaid p Sponsor s SSN FECA HEALTH PLAN SSN or ID Medicaid BLK LUNG p SSN 3. 28. TOTAL CHARGE 29. AMOUNT PAID 33. BILLING PROVIDER INFO PH 30. BALANCE DUE OMB No. 1240-0044 Expires 12/31/2015 PHYSICIAN OR SUPPLIER INFORMATION Instructions for Completing OWCP-1500 Health Insurance Claim Form For Medical Services Provided Under...

How to fill out DoL OWCP-1500

How to fill out DoL OWCP-1500

1. Obtain the DoL OWCP-1500 form from the Department of Labor website or your employer's HR department.
2. Fill in the patient's personal information, including their name, address, and date of birth in the designated fields.
3. Complete the 'Insured's ID Number' section with the employee's Social Security Number.
4. Enter the date of service when the medical treatment was provided.
5. Provide a detailed description of the services rendered, including the procedure codes.
6. Specify the place of service by selecting the appropriate code from the provided list.
7. Fill in the charges section with the amount billed for each service rendered.
8. Sign and date the form at the bottom to certify that the information is accurate and complete.
9. Submit the completed OWCP-1500 form to the appropriate claims office as specified by the Department of Labor.

Who needs DoL OWCP-1500?

1. The DoL OWCP-1500 form is needed by healthcare providers who are billing for medical services provided to federal workers who have filed a claim for work-related injuries or illnesses under the Federal Employees Compensation Act (FECA).

People Also Ask about

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Medical insurance does not allow coverage extensions and add-ons. Health insurance offers add-ons for various healthcare needs such as maternity, accidents, critical illness, etc.

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Medi-Cal is California's Medicaid program. This is a public health insurance program that provides free or low cost medical services for children and adults with limited income and resources.

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Medi-Cal, California's Medicaid program, is a public insurance health care program which provides health care services for low-income individuals and families who meet defined eligibility requirements.

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Medi-Cal is health coverage, just like the coverage offered through Covered California. Medi-Cal provides benefits similar to the coverage options available through Covered California, but often at lower or no cost to you or your family.

What type of health insurance is Medi-Cal?

Medi-Cal, California's Medicaid program, is a public insurance health care program which provides health care services for low-income individuals and families who meet defined eligibility requirements.

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What is DoL OWCP-1500?

The DoL OWCP-1500 is a claim form used for billing and submitting medical services provided to injured workers under the Department of Labor's Office of Workers' Compensation Programs (OWCP).

Who is required to file DoL OWCP-1500?

Healthcare providers who render medical services to injured federal workers and seek reimbursement for those services are required to file the DoL OWCP-1500.

How to fill out DoL OWCP-1500?

To fill out the DoL OWCP-1500, providers must complete the required patient information, details of the services rendered, diagnosis codes, and the charges associated with the services, ensuring all fields are accurately filled and signed where necessary.

What is the purpose of DoL OWCP-1500?

The purpose of DoL OWCP-1500 is to provide a standardized format for healthcare providers to submit claims for payment for medical services, ensuring proper processing and reimbursement under the OWCP.

What information must be reported on DoL OWCP-1500?

The information that must be reported on DoL OWCP-1500 includes patient demographics, provider information, dates of service, procedure codes, diagnosis codes, and the total charges for the medical services provided.