Item 1 - Type of insurance held by the patient.
- Item 1a - ID# of the patient insured by the policy
Item 2 - Patient's full name [last name, first name, middle initial], exactly how it shows on the insurance card
Item 3 - Patient's date of birth [MM DD YYYY] and sex [M/F]
Item 4 - The name of the insurance policy holder. If the patient and the insured are the same person then write SAME
Item 5 - Patient's full address and telephone #
Item 6 - Relationship of the patient to the policyholder
Item 7 - Full address of the insured. If the address is the same as the patient's then write SAME
Item 8 - Marriage and employment status of the patient. Medicare is the only insurance that this box should stay blank.
Item 9 - Other insured's name. This will be used IF the patient is covered by secondary health coverage.
- Item 9a - group # of secondary insurance
- Item 9b - date of birth and sex of policyholder
-
Item 9c - employer or school attended
- Item 9d - name of the company or plan
Item 10 - "yes" or "no" regarding patients conditions. Automobile, work, or other possible liability claims are different.
- Item 10d - Local use.
Item 11 - Policy # of primary policy
- Item 11a - Insured's birthday and sex
- Item 11b - Employer or school attended
- Item 11c - name of the company or plan
Item 12 - Signature for release of information
Item 13 - Signature for permission to authorize payment from the third-party payer to the healthcare provider
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For Medicare, for the current illness, injury, or pregnancy, enter either an 8-digit [MMDDCCYY] or 6-digit [MMDDYY] date. For chiropractic services, enter the date of the initiation of the course of treatment and enter the date of xray [if used to demonstrate subluxation] in item 19. Medicare does not use qualifiers.
For commercial claims: Enter the date of the first date of the present illness, injury, or pregnancy. For pregnancy, use the date of the last menstrual period [LMP] as the first date. Enter the applicable qualifier to identify which date is being reported [e.g., 431 Onset of Current Symptoms or Illness, 484 Last Menstrual Period].
This is where the National Provider Identifier [NPI] number goes. As part of the enrollment process, all providers must apply for an NPI number. Authorized under the HIPAA Simplification Rule, the NPI is a unique identification number for all HIPAA-covered entities, including individuals, organizations, home health agencies, clinics, nursing homes, residential treatment homes, laboratories, ambulances, group practices, and health maintenance organizations [HMOs].
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