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).

Instructions and Help about DoL OWCP-1500

Hello this is Joe Moore and I thought I would give you some instructions on how to properly complete a CMS claim form first thing you want to remember is that everything has to be in caps, and also you can't use cannot use any abbreviations when you complete a claim form, so we'll start with block 1, and you'll notice that you need to place an X in one of these blocks to indicate the type of insurance that you have so if you have Medicare or Medicaid or TRI CARE or Chap or group plan or FIFA or other you would mark an X in the appropriate slot in 1a you're going to demarcate the patient's ID number for their insurance this number has to have no dashes and no spaces so even if the card presents that way you are to type it in with no spaces and no dashes they have a group health number we put the group health number over here farther on the line, so you'd space down and place it over here to the far right of the line then going to come over here to block 2, and you're going to complete the patient's name, so you're going to type in the patient's last name comma space first name comma space and then the middle initial if they have a junior attached to their name you would type in Smith space Junior comma space John comma space a for instance if they're a doctor or have a title with their name we do not include that on the claim form underneath that then in the next block you're going to enter the patient's mailing address again we do not use abbreviations so if it's Avenue Road Street any of that you're going to type that out completely put in their City and their two two-digit state on F alphabet put in the zip code this is one of the few places you can put in a dash so if they have the elongated four-digit zip code you'll just add in the first five digits comma and then the next four digits for their phone number you can see there's already a parenthesis to put in the area code and then when you type in their phone number you type it as one long seven-digit number you do not put in a stat a dash or a space let's go up here to block three up here going to put in the patient's a date of birth, and you can see that you need to have month day, and they write century year, so you need eight digits you also need to put an X in either the male or the female box underneath it of lock six you're going to take pipe type in the relationship of the patient to the insured so if it's self or their spouse or their child or other indicates either a domestic partnership or you could also ensure your parents, so you would stick in the other in that box, and then you have the patient status whether they're single or married or other again the other is if they're a domestic partnership you'll want to put that in then I mean underneath that we have whether they are employed a full-time student or a part-time student, so a lot of insurance companies will ensure your child till their 4:25 if they are full-time students and now filling out block ten down the middle this...

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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.