????!@&@Z"Arial&Gz?{Gz?Gz?|?5^$@&{Gz @{Gz?{Gz @h|?$@d"Arialjt?5^I ?@K7A`?HEALTH INSURANCE CLAIM FORM+Gz?{Gz?@/$?+jt?h|?$@@/$?+Gz?= ףp=@@/$?+"~@tV?{Gz?K7A`@<"Arial?E?5^I ??1. MEDICARE<"Arial?E?tV?q= ףp?MEDICAID<"Arial^I +@E?5^I ?q= ףp?CHAMPVA<"Arial^I + @E?MbX?x&1?GROUP HEALTH PLAN <"Arial^I +@E?y&1?MbX?FECA BLK LUNG<"Arial/$@E??q= ףp?OTHER &Gz?Gz?{Gz @Gz?&Gz?333333?Q @333333?&Gz?{Gz@{Gz @{Gz@<"Arialy&1?ףp= ??㥛 ?(Medicare #)<"Arial/$?ףp= ?jt?㥛 ?(Medicaid #)<"ArialS?ףp= ??㥛 ?(Sponsor's SSN)<"Arialn@ףp= ??㥛 ?(Member ID#)<"Arial"~j @ףp= ??㥛 ?(SSN or ID)<"Arial(\u@ףp= ?MbX?㥛 ?(SSN)<"Arialn@ףp= ?Mb?㥛 ?(ID)+ʡE??Q?Q?+5^I ??Q?Q?+= ףp=??Q?Q?+)\(@?Q?Q?+Gz @?Q?Q?+@?Q?Q?+@?Q?Q?<"Arialp= ף?)\(?Q@㥛 ?2. PATIENT'S NAME (Last Name, First Name, Middle Initial)&Gz @Gz?Gz @Gz@&Gz?Gz@{Gz @Gz@<"Arial @)\(?/$?q= ףp?3. PATIENT'S BIRTH DATE<"ArialGz@E?5^I ?㥛 ?1a. INSURED'S I.D. NUMBER& @"~? @333333?&Q@"~?)\(@^I +?<"Arial ףp= @)\(?tV@㥛 ?4. INSURED'S NAME (Last Name, First Name, Middle Initial)<"Arial @/$?Mb?HzG?MM<"Arial/$ @/$?Q?K7A`?DD<"Arialףp= @/$?Q?K7A`?YY<"Arial^I @)\(?Mb?Mb?SEX<"Arial(\B@^I +?q= ףp?㥛 ?M<"Arialffffff@^I +?㥛 ?㥛 ?F+(\@?Q?Q?+n@?Q?Q?&Gz?@Gz @@&Gz?x@{Gz @x@&Gz?ffffff @Gz @ffffff @<"Arialp= ף?S?/$?K7A`?5. PATIENT'S ADDRESS (No., Street)<"Arial @S?/$?K7A`?6. PATIENT RELATIONSHIP TO INSURED<"Arial ףp= @S?/$?K7A`?7. INSURED'S ADDRESS (No., Street)&zG@@{Gz @@&Gz? @Gz @ @&Gz?@Gz @@<"Arialp= ף @tV@K7A`??Self<"ArialQ @tV@㥛 ??Spouse<"Arial(\@tV@x&1??Child<"Arialfffff@tV@Zd;O??Other+= ףp= @= ףp=@Q?Q?+y&1,@= ףp=@Q?Q?+@= ףp=@Q?Q?+E@= ףp=@Q?Q?<"Arialp= ף?/$@㥛 ?㥛 ?CITY&Gz?= ףp=@{Gz @= ףp=@<"Arial ףp= @/$@㥛 ?㥛 ?CITY<"Arial @/$@5^I ?㥛 ?8. PATIENT STATUS<"Arialp= ף?@jt?㥛 ?ZIP CODE&Dl@{Gz@Dl@@&Qk@{Gz@Qk@@&}?5^I?@}?5^I?x@& ףp= @@ ףp= @x@<"Arial ףp= @@jt?㥛 ?ZIP CODE+ףp= @n@Q?Q?<"Arialn @Q@Q?㥛 ?Single<"Arial ףp= @Q@x&1?㥛 ?Married<"Arial= ףp@Q@Zd;O?㥛 ?Other<"ArialQ @tV@p= ף?㥛 ?Employed<"ArialGz@tV@?q= ףp?Full-Time<"ArialGz@@?㥛 ?Student<"Arialn@@tV@??Part-Time<"Arialn@@Q@?㥛 ?Student+ףp= W@n@Q?Q?+E@n@Q?Q?+@y&1@Q?Q?+ףp= W@y&1@Q?Q?+ףp= @y&1@Q?Q?<"Arial@/$@㥛 ?㥛 ?STATE<"Arial/$@/$@㥛 ?㥛 ?STATE<"ArialHzG?ˡE@tV@㥛 ?9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)<"Arialsh|? @ˡE@y&1?㥛 ?10. IS PATIENT'S CONDITION RELATED TO:<"ArialGz@ˡE@/$@㥛 ?11. INSURED'S POLICY GROUP OR FECA NUMBER&zG@HzG @{Gz @HzG @&zG@@{Gz @@<"Arial5^I ?@^I +?㥛 ?TELEPHONE (Include Area Code)&zG@{Gz @{Gz @{Gz @<"Arialh|?5@@E?㥛 ?TELEPHONE (Include Area Code)<"Arialp= ף?"~j @/$@㥛 ?a. OTHER INSURED'S POLICY OR GROUP NUMBER<"Arial @"~j @y&1?㥛 ?a. EMPLOYMENT? (Current or Previous)<"Arial ףp= @"~j @tV?㥛 ?a. INSURED'S DATE OF BIRTH&jt? ףp=@{Gz @ ףp=@& ףp= @= ףp=@ ףp= @K7A@&jt?K7A@{Gz @K7A@&Gz?Gz.@{Gz @Gz.@&zG@(\@{Gz @(\@&jt?K7A@n@K7A@&n@K7A@n@@&zG@Q@{Gz @Q@&/$@K7A@/$@@&n@"~@n@@&^I +@K7A@^I +@@&jt?n@{Gz @n@&jt?@{Gz @@&jt?n @{Gz @n @&jt?"~ @{Gz @"~ @&jt?nJ!@{Gz @nJ!@&jt?㥛 !@{Gz @㥛 !@&Gz?"@{Gz @"@&Gz? ףp=J#@{Gz @ ףp=J#@+ףp= @zG @Q?Q?+ףp= @{Gz@Q?Q?+ףp= @Gz@Q?Q?+RQ@zG @Q?Q?+RQ@{Gz@Q?Q?+RQ@Gz@Q?Q?<"Arialsh|?@E @x&1?㥛 ?YES<"Arialsh|?@/$@Zd;O?㥛 ?YES<"Arialsh|?@/$@Zd;O?㥛 ?YES<"Arial@E @x&1?㥛 ?NO<"Arial@/$@-?㥛 ?NO<"Arial@/$@x&1?㥛 ?NO&^I @E @^I @HzG @& ףp=@E @ ףp=@HzG @<"Arial9v@^I + @Mb??MM<"ArialQ@^I + @+??DD<"ArialGz@^I + @-?HzG?YY<"Arial(\B@Q @9v?㥛 ?SEX<"ArialGz@Gz @Mb?㥛 ?M<"Arial(\@Gz @sh|??㥛 ?F+Gz@Gz @Q?Q?+Q@Gz @Q?Q?<"Arial?tV @y&1??b. OTHER INSURED'S DATE OF BIRTH<"Arial @tV @?㥛 ?b. AUTO ACCIDENT?<"Arial ףp= @tV @^I +?㥛 ?b. EMPLOYER'S NAME OR SCHOOL NAME<"Arial(\u@tV @jt?㥛 ?PLACE (State)<"Arialp= ף?E@/$?㥛 ?c. EMPLOYER'S NAME OR SCHOOL NAME<"Arial @E@tV?㥛 ?c. OTHER ACCIDENT?<"Arial ףp= @E@Dl?㥛 ?c. INSURANCE PLAN NAME OR PROGRAM NAME<"Arialp= ף?n@@n@㥛 ?d. INSURANCE PLAN NAME OR PROGRAM NAME<"Arial @n@@?㥛 ?10d. RESERVED FOR LOCAL USE<"Arial ףp= @n@@tV?㥛 ?d. IS THERE ANOTHER HEALTH BENEFIT PLAN?+jt?"~?y&1??&y&1?tV?y&1?"~?&Dl?tV?Dl?"~?<"Arialjt?tV??㥛 ?PICA<"ArialE@tV?9v?㥛 ?PICA&Gz?\(\@Gz?@&jt?tV@jt?E@&Q?tV@Q?E@& ףp= @(\@)\(@(\@& ףp= @@ ףp= @(\@&)\(@@)\(@(\@<"Arialףp= ?/$@E@㥛 ?READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM<"Arial?@"~j@㥛 ?12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary#<"Arial?K7A`@K7A@㥛 ?to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment<"ArialRQ?n@MbX?㥛 ?below.<"ArialGz@Q@"~j@㥛 ?13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize&tV?/$@/$ @/$@&/$@/$@K7A@/$@&9v@/$@{Gz @/$@&-?E@-? ףp=@&?E@? ףp=@<"Arial(\@E??㥛 ?(For Program in Item 1)<"Arial/$@(\@/$@㥛 ?payment of medical benefits to the undersigned physician or supplier for<"Arial9v@"~j@Gz?㥛 ?services described below.+Q@(\@Q?Q?+33333@(\@Q?Q?+sh|?@/$@HzG?HzG?+ ףp= @(\@Q?Q?&n@E@n@ ףp=@&@E@@ ףp=@&@E@@ ףp=@&K7A@E@K7A@ ףp=@&^I +@E@^I +@ ףp=@&K7A`@E@K7A`@ ףp=@&@^I +@@K7A@&K7A@^I +@K7A@K7A@&^I +@^I +@^I +@K7A@&K7A`@^I +@K7A`@K7A@+^I @(\@Q?Q?+^I @(\@Q?Q?+ ףp= ?{G"@Q?Q?+Gz@{G"@HzG?HzG?+ ףp= @{G"@HzG?HzG?+ ףp= @{G"@HzG?HzG?&(\u@(\u@(\u@^I +@&L@(\u@L@^I +@&(\u@E@(\u@ ףp=@&?"~j@?(\u@&"~?"~@?K7A`@&"~?"~@?(\u@&(\u@"~@(\u@@&/$@"~@/$@@&(\@"@(\@|?5^$@&p= ף@"@p= ף@ ףp=J#@&/$?^I +@/$?n@&nJ@"@nJ@ ףp=J#@& ףp= @K7A`@"~j@K7A`@&"~j@K7A`@"~j@7A`@<"Arial(\?Gz@Mb??MM<"ArialQ?Gz@㥛 ??DD<"Arial^I +?Gz@K7A`??YY<"Arial(\?Dl@Mb?㥛 ?M<"ArialRQ@Dl@㥛 ?㥛 ?F<"ArialK7A`@@x&1?㥛 ?YES<"Arial@ ףp= @x&1?㥛 ?NO<"Arial@tV @MbX?㥛 ?SEX&(\@㥛 "@(\@nJ#@&"~@㥛 "@"~@nJ#@&^I @㥛 "@^I @nJ#@&tV @^I +@tV @@<"ArialK7A@/$@Q?㥛 ?If yes<"Arialh|?@/$@tV?㥛 ?, return to and complete item 9 a-d.<"Arial?n@-??SIGNED<"Arialn@n@-??SIGNED<"Arialn @n@p= ף??DATE<"Arialp= ף?ET@Gz?q= ףp?14. DATE OF CURRENT:<"ArialtV@ET@n@q= ףp?15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS<"Arial ףp= @ET@/$@?16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION<"Arial-?^I @Mb??MM<"ArialDl?^I @㥛 ??DD<"ArialS?^I @K7A`??YY<"ArialE@^I @Mb??MM<"Arial^I +@^I @㥛 ??DD<"ArialK7A`@^I @K7A`??YY<"Arial/$@^I @Mb??MM<"Arial"~@^I @㥛 ??DD<"Arial9v@^I @K7A`??YY<"Arialn@@^I @Mb??MM<"Arial ףp=@^I @㥛 ??DD<"Arialn@^I @K7A`??YY<"Arial/$@"~@Mb??MM<"Arial"~@"~@㥛 ??DD<"Arial9v@"~@K7A`??YY<"Arialn@@"~@Mb??MM<"Arial ףp=@"~@㥛 ??DD<"Arialn@"~@K7A`??YY<"Arial"~j @^I @Gz?㥛 ?GIVE FIRST DATE<"Arialy&1?ET@tV?㥛 ?ILLNESS (First symptom) OR<"Arialy&1?h|?@y&1?㥛 ?INJURY (Accident) OR<"Arialy&1?9v@tV?㥛 ?PREGNANCY (LMP)<"Arial@@Cl??FROM<"Arial@ET@Cl??FROM<"Arial ףp=@@+??TO<"Arial ףp=@ET@-??TO<"Arialp= ף?Gz@^I +@㥛 ?17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE<"ArialGz@Gz@Gz@㥛 ?18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES<"Arialp= ף?"~@E?㥛 ?19. RESERVED FOR LOCAL USE<"Arial ףp= @"~@y&1?㥛 ?20. OUTSIDE LAB?<"Arial(\@"~@MbX??$ CHARGES<"ArialnJ@9v@x&1?㥛 ?YES<"ArialK7A`@9v@x&1?㥛 ?NO<"ArialHzG?Q8@n@q= ףp?21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (Relate Items 1, 2, 3 or 4 to Item 24E by Line)<"ArialGz@Q8@E?㥛 ?22. MEDICAID RESUBMISSION<"Arial/$@@㥛 ?㥛 ?CODE<"Arial@@tV?㥛 ?ORIGINAL REF. NO.<"Arial ףp= @/$@?㥛 ?23. PRIOR AUTHORIZATION NUMBER<"Arial?@MbX?㥛 ?24. A.<"Arial^I +@@㥛 ?㥛 ?B.<"Arial^I +@@㥛 ?㥛 ?C.<"Arial9v@@㥛 ?㥛 ?E.<"Arial@@㥛 ?㥛 ?F.<"ArialK7A@@㥛 ?㥛 ?G.<"Arial/$@@㥛 ?㥛 ?H.<"ArialnJ@@㥛 ?㥛 ?I.<"Arial9v@@㥛 ?㥛 ?J.&ˡE?nJ@ˡE?9v@&ˡE?9v@Gz?9v@<Times New Romany&1?ET@T㥛 ?㥛 ?.&tV?9v@S?9v@<"ArialCl?ET@Mb?㥛 ?1.<"ArialMbX?@y&1?Mb?DATE(S) OF SERVICE<"ArialDl?^I @Q?q= ףp?From<"Arial/$?^I @K7A`?㥛 ?To<"ArialCl?/$@Q?q= ףp?MM<"Arial-?/$@K7A`?q= ףp?DD<"Arial)\(?/$@K7A`?q= ףp?YY<"Arialy&1?/$@Q?q= ףp?MM<"ArialS?/$@K7A`?q= ףp?DD<"Arial)\(?/$@K7A`?q= ףp?YY<"ArialE@^I @㥛 ?q= ףp?PLACE OF<"Arial@/$@p= ף?q= ףp?SERVICE<"ArialtV@(\@tV?q= ףp?D. PROCEDURES, SERVICES, OR SUPPLIES<"Arial/$@^I @y&1?q= ףp?(Explain Unusual Circumstances)<"ArialtV@/$@y&1?㥛 ?CPT/HCPCS<"ArialtV@/$@?㥛 ?MODIFIER<"Arial"~@^I @jt?Mb?DIAGNOSIS<"Arial9v@/$@??POINTER<"Arial^I @ ףp= @y&1??$ CHARGES<"Arial/$@"~j@?q= ףp?DAYS<"Arialn@n@K7A`?q= ףp?OR<"Arial@9v@㥛 ?q= ףp?UNITS<"Arial^I @"~j@y&1?q= ףp?EPSDT<"Arial^I @n@?q= ףp?Family<"ArialK7A@9v@㥛 ?q= ףp?Plan<"Arialn@/$@?q= ףp?EMG<"Arial@h|?@Gz?q= ףp?RENDERING<"ArialnJ@/$@-?q= ףp?PROVIDER ID. #<"Arialp= ף?Q"@"~?㥛 ?25. FEDERAL TAX I.D. NUMBER<"Arial)\(?v"@Mb?㥛 ?SSN<"ArialQ@v"@Mb?㥛 ?EIN<"Arial\(\@Q"@"~?㥛 ?26. PATIENT'S ACCOUNT NO.<"Arial@Q"@tV?㥛 ?27. ACCEPT ASSIGNMENT?<"Arial"~j@Q"@5^I ?㥛 ?(For govt. claims, see back)<"ArialK7A@Q#@x&1?㥛 ?YES<"Arial"~@Q#@x&1?㥛 ?NO<"ArialGz@Q"@Gz?㥛 ?28. TOTAL CHARGE<"ArialˡE}@Q"@MbX?㥛 ?29. AMOUNT PAID<"Arialn@@Q"@jt?㥛 ?30. BALANCE DUE<"Arial9v@#@HzG?㥛 ?$<"Arial/$@#@HzG?㥛 ?$<"Arial"~j@#@HzG?㥛 ?$<"Arialp= ף?nJ#@/$?㥛 ?31. SIGNATURE OF PHYSICIAN OR SUPPLIER<"ArialˡE?h|?#@/$?㥛 ?(I certify that the statements on the reverse<"ArialˡE?L7A`#@/$?㥛 ?apply to this bill and are made a part thereof.)<"Arial\(\?Q$@?㥛 ?SIGNED<"Arialףp= ?Q$@?㥛 ?DATE<"ArialˡE?#@/$?㥛 ?INCLUDING DEGREES OR CREDENTIALS<"ArialtV@nJ#@/$@㥛 ?32. SERVICE FACILITY LOCATION INFORMATION<"Arial@nJ#@^I +?㥛 ?33. BILLING PROVIDER INFO & PH #&K7@7A`@V-@7A`@&K7@7A`@"~j@K7@&"~j@K7@V-@7A`@&sh|? @nJ@sh|? @9v@&sh|? @9v@Q @9v@<Times New Roman^I + @ET@T㥛 ?㥛 ?.&/$ @9v@Dl@9v@<"Arial^I + @ET@Mb?㥛 ?3.&sh|? @(\u@sh|? @n@&sh|? @n@Q @n@<Times New Roman^I + @@T㥛 ?㥛 ?.&/$ @n@Dl@n@<"Arial^I + @@Mb?㥛 ?4.&ˡE?(\u@ˡE?n@&ˡE?n@Gz?n@<Times New Romany&1?@T㥛 ?㥛 ?.&tV?n@S?n@<"ArialCl?@Mb?㥛 ?2.&@h|?5@"~@h|?5@<"Arial^I +@K7A`@K7A`?㥛 ?17b.&/$ @^I +@/$ @K7A@&tV @^I +@tV @K7A@<"ArialQ @K7A`@K7A`?㥛 ?NPI&Dl?^I +@Dl?n@&RQ?^I +@RQ?n@&E?^I +@E?n@&)\(?^I +@)\(?n@&n@^I +@n@n@&^I +@^I +@^I +@n@&/$@^I +@/$@n@&tV @^I +@tV @n@&@^I +@@n@&/$@^I +@/$@n@&^I @^I +@^I @n@&n@^I +@n@n@&"~@^I +@"~@n@&/$@^I +@/$@n@&(\u@^I +@(\u@n@&/$@^I +@/$@n@<"Arial9v@9v@+?q= ףp?ID.<"Arial"~@ ףp= @S?q= ףp?QUAL.P"Arial@h|?5@x&1?q= ףp?NPI&/$ @Zd;ߏ$@Q@Zd;ߏ$@&K7A@/$"@K7A@Zd;ߏ$@<"ArialtV@L7A`$@㥛 ?㥛 ?a.<"Arial9v@L7A`$@㥛 ?㥛 ?a.+nJ@n$@y&1?MbX?<"Arial@L7A`$@㥛 ?㥛 ?b.+/$ @n$@tV?MbX?<"Arial @"~$@㥛 ?㥛 ?b.+jt?@9v@K7A`?&Dl?(\u@Dl?n @&Dl?(\u@Dl?n @&RQ?(\u@RQ?n @&E?(\u@E?n @&)\(?(\u@)\(?n @&E@(\u@E@n @&^I +@(\u@^I +@n @&/$@(\u@/$@n @&tV @(\u@tV @n @&@(\u@@n @&/$@(\u@/$@n @&^I @(\u@^I @n @&n@(\u@n@n @&"~@(\u@"~@n @&9v@(\u@9v@n @&@(\u@@n @&9v@(\u@9v@n @P"Arial@@x&1?q= ףp?NPI&Dl?/$U @Dl?L7A` @&Dl?/$U @Dl?L7A` @&RQ?/$U @RQ?L7A` @&E?/$U @E?L7A` @&)\(?/$U @)\(?L7A` @&E@/$U @E@L7A` @&^I +@/$U @^I +@L7A` @&/$@/$U @/$@L7A` @&tV @/$U @tV @L7A` @&@/$U @@L7A` @&/$@/$U @/$@L7A` @&^I @/$U @^I @L7A` @&n@/$U @n@L7A` @&"~@/$U @"~@L7A` @&9v@/$U @9v@L7A` @& ףp=@/$U @ ףp=@L7A` @&9v@/$U @9v@L7A` @P"Arial@K7A` @x&1?q= ףp?NPI&Dl?{G @Dl?nJ!@&Dl?{G @Dl?nJ!@&RQ?{G @RQ?nJ!@&E?{G @E?nJ!@&)\(?{G @)\(?nJ!@&E@{G @E@nJ!@&^I +@{G @^I +@nJ!@&/$@{G @/$@nJ!@&tV @{G @tV @nJ!@&@{G @@nJ!@&/$@{G @/$@nJ!@&^I @{G @^I @nJ!@&n@{G @n@nJ!@&"~@{G @"~@nJ!@&9v@{G @9v@nJ!@& ףp=@{G @ ףp=@nJ!@&9v@{G @9v@nJ!@P"Arial@!@x&1?q= ףp?NPI&Dl?K7A!@Dl?㥛 !@&Dl?K7A!@Dl?㥛 !@&RQ?K7A!@RQ?㥛 !@&E?K7A!@E?㥛 !@&)\(?K7A!@)\(?㥛 !@&E@K7A!@E@㥛 !@&^I +@K7A!@^I +@㥛 !@&/$@K7A!@/$@㥛 !@&tV @K7A!@tV @㥛 !@&@K7A!@@㥛 !@&/$@K7A!@/$@㥛 !@&^I @K7A!@^I @㥛 !@&n@K7A!@n@㥛 !@&"~@K7A!@"~@㥛 !@&9v@K7A!@9v@㥛 !@& ףp=@K7A!@ ףp=@㥛 !@&9v@K7A!@9v@㥛 !@P"Arial@L7A`!@x&1?q= ףp?NPI&Dl?QE"@Dl?/$"@&Dl?QE"@Dl?/$"@&RQ?QE"@RQ?/$"@&E?QE"@E?/$"@&)\(?QE"@)\(?/$"@&E@QE"@E@/$"@&^I +@@"@^I +@/$"@&/$@@"@/$@/$"@&tV @@"@tV @/$"@&@@"@@/$"@&/$@@"@/$@/$"@&^I @@"@^I @/$"@&n@@"@n@/$"@&"~@QE"@"~@/$"@&9v@QE"@9v@/$"@& ףp=@QE"@ ףp=@/$"@&9v@QE"@9v@/$"@P"Arial@Zd;O"@x&1?q= ףp?NPI+jt?n@/$@K7A`?+jt?n @/$@K7A`?+jt?L7A` @/$@K7A`?+jt?nJ!@/$@K7A`?+jt?㥛 !@/$@K7A`?+@@Q@Mb?&/$ @@/$ @^I +@<"Arial^I +@^I @K7A`?㥛 ?17a.&tV @@tV @^I +@<"Arialjt?tV?sh|?@K7A`?APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05"ArialMbX??jt?Q?1500+jt??Gz?Q?+K7A@"~?/$?K7A`@&ET@Zd;ߏ$@K7A@Zd;ߏ$@+h|?@"~?y&1??&n @tV?n @"~?&@ @tV?@ @"~?<"Arial/$?E?tV?MbX?TRICARE CHAMPUS&n@"~@n@/$"@&(\@"~@(\@v"@dTimes New Roman(\@@jt?K7A`? 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Z"Arial?/$$@/$@Mb?tZ"ArialS?㥛 p$@RQ?Mb?%02m %02D %YZ"Arial^I +@Zd;O#@5^I ?K7A`?/Z"Arial^I +@jt?Gz@MbX?0Z"Arial^I +@y&1?@y&1?fZ"Arial?ףp= ??K7A`?gZ"ArialS?ףp= ???hZ"Arialy&1?ףp= ???iZ"ArialtV@ףp= ???mZ"ArialQ @ףp= ???jZ"Arialh|?@ףp= ???kZ"Arial/$@ףp= ???@Z"Arial^I +@^I +?^I +@Mb?Z"ArialQ @5^I ?MbX?㥛 ?%02mZ"ArialtV @5^I ?MbX?㥛 ?%02DZ"Arialn@5^I ?y&1?㥛 ?%YEZ"ArialK7A@5^I ?㥛 ?Mb?FZ"ArialK7A@5^I ?q= ףp?Mb?Z"Arial?@^I +@Mb?nZ"Arial/$ @tV@K7A`?Mb?oZ"ArialnJ@tV@㥛 ?Mb?pZ"Arial"~@tV@K7A`?Mb?qZ"Arial"~@tV@Mb?Mb?Z"Arial^I +@@^I +@Mb?Z"Arial?/$@/$@Mb?Z"ArialQ@/$@x&1?Mb?Z"ArialGz@Q@㥛 ?Mb?if [Patient Marital Status] = "S" then "X" endifZ"Arial"~j@Q@㥛 ?Mb?if [Patient Marital Status] = "M" then "X" endifZ"Arial"~@Q@㥛 ?Mb?if [Patient Marital Status] <> "S" and [Patient Marital Status] <> "M" then "X" endifLZ"Arial^I +@/$@@Mb?MZ"Arial/$@/$@x&1?Mb?Z"Arial?tV@ףp= ?Mb?Z"Arial/$?"~j@5^I ?Mb?Z"ArialGz@n@㥛 ?Mb?if [Patient Employment Status] = "F" or [Patient Employment Status] = "P" then "X" endifZ"Arial"~j@n@㥛 ?Mb?if [Patient Student Status] = "F" then "X" endifZ"Arial"~@n@㥛 ?Mb?if [Patient Student Status] = "P" then "X" endifNZ"Arial^I +@"~j@tV?Mb?OZ"Arial/$@"~j@5^I ?Mb?Z"Arial?Q@Q@Mb?[Secondary Insured Last Name] + ", " + [Secondary Insured First Name] + " " + [Secondary Insured Middle Initial]?Z"Arial9v@ @/$@Mb?Z"Arial?/$ @@Mb?GZ"ArialGz@ @㥛 ?Mb?HZ"Arial"~j@ @q= ףp?Mb?PZ"Arial/$@^I + @MbX?㥛 ?%02mPZ"Arialn@^I + @MbX?㥛 ?%02DPZ"Arial(\@^I + @jt?㥛 ?%YZ"Arial^I +@^I + @㥛 ?Mb?if [Primary Insured Sex] = "M" then "X" endifZ"Arial9v@^I + @㥛 ?Mb?if [Primary Insured Sex] = "F" then "X" endifZ"Arialjt?Dl@MbX?㥛 ?%02mZ"Arialy&1?Dl@MbX?㥛 ?%02DZ"Arial^I +?Dl@jt?㥛 ?%YZ"Arial/$@Dl@㥛 ?Mb?if [Secondary Insured Sex] = "M" then "X" endifZ"Arialsh|?@Dl@㥛 ?Mb?if [Secondary Insured Sex] = "F" then "X" endifZ"ArialGz@/$@㥛 ?Mb?if [Box - Auto Accident] = "X" then "X" endifZ"Arial"~j@/$@㥛 ?Mb?if [Box - Auto Accident] <> "X" then "X" endifZ"Arial^I +@^I +@?Mb?if [Box - Auto Accident] = "X" then [Accident State] endifSZ"Arial^I +@tV@@Mb?Z"Arial?@@Mb?Z"ArialGz@9v@㥛 ?Mb?if [Box - Other Accident] = "X" then "X" endifZ"Arial"~j@9v@㥛 ?Mb?if [Box - Other Accident] <> "X" then "X" endif/Z"Arial^I +@@@Mb?oZ"Arial?n@/$@Mb?Z"ArialE@ ףp= @㥛 ?Mb?if [Secondary Insurance Indicator] = "Y" then "X" endifZ"Arialn@ ףp= @㥛 ?Mb?if [Secondary Insurance Indicator] <> "Y" then "X" endifZ"Arial5^I ?K7A`@n@Mb?tZ"Arial@K7A`@?Mb?%02m %02D %YZ"Arial^I @K7A`@@Mb?Z"Arialjt?(\@MbX?㥛 ?if [Symptom Date] <> "" then [Symptom Date] else [Accident Date] endif%02mZ"Arialy&1?(\@MbX?㥛 ?if [Symptom Date] <> "" then [Symptom Date] else [Accident Date] endif%02DZ"Arial5^I ?(\@MbX?㥛 ?if [Symptom Date] <> "" then [Symptom Date] else [Accident Date] endif%YZ"Arial/$@(\@MbX?㥛 ?%02mZ"Arial@(\@MbX?㥛 ?%02DZ"Arialn@@(\@?㥛 ?%YZ"Arial/$@(\@MbX?㥛 ?%02mZ"Arialn@(\@MbX?㥛 ?%02DZ"Arial@(\@x&1?㥛 ?%YZ"Arialn@@(\@MbX?㥛 ?%02mZ"Arial(\u@(\@MbX?㥛 ?%02DZ"Arial^I @(\@y&1?㥛 ?%YZ"Arial/$@ET@MbX?㥛 ?%02mZ"Arialn@ET@MbX?㥛 ?%02DZ"Arial@ET@x&1?㥛 ?%YZ"Arialn@@ET@MbX?㥛 ?%02mZ"Arial(\u@ET@MbX?㥛 ?%02DZ"Arial^I @ET@y&1?㥛 ?%YvZ"Arial\(\?(\u@/$@Mb?OZ"Arialn@9v@㥛 ?㥛 ?PZ"Arialn@9v@㥛 ?㥛 ?Z"Arial(\u@"~j@MbX?Mb?%dZ"Arial@K7A`@y&1?Mb?%02cZ"Arial@K7A@^I +?㥛 ?if [Primary Insurance Type] = "E" then [Medicaid Resubmission Number] endifZ"Arial/$@K7A@?㥛 ?if [Primary Insurance Type] = "E" then [Medicaid Original Reference Number] endifwZ"ArialDl?K7A@/$?Mb?yZ"ArialDl?/$@/$?Mb?{Z"Arial"~j @K7A@/$?Mb?}Z"ArialtV @^I +@/$?Mb?CZ"Arial/$ @h|?5@ףp= ?Mb? Z"Arial@K7A$@MbX?㥛 ?Z"Arial^I +@h|?5$@/$@K7A`?[Practice City] " " [Practice State] " " [Practice Zip Code]Z"Arial^I +@K7A#@/$@K7A`?[Practice Address Line 1] [Practice Address Line 2]4Z"ArialMbX??/$@Mb?DashOnly [Patient Last Name] NoStrip ", " NoStripEnd [Patient First Name] NoStrip ", " NoStripEnd [Patient Middle Initial] DashOnlyEnd~Z"ArialnJ@?n@Mb?if [Primary Insured Last Name] <> "" then DashOnly [Primary Insured Last Name] NoStrip ", " NoStripEnd [Primary Insured First Name] NoStrip ", " NoStripEnd [Primary Insured Middle Initial] DashOnlyEnd endifZ"ArialMbX?9v@Gz@K7A`?[Referring Physician First Name] " " [Referring Physician Last Name]Z"Arial^I +@n#@/$@K7A`?DashOnly [Practice Name] DashOnlyEnd2Z"Arial"~j@/$$@-?-?if [Provider Group National Provider ID] <> "" then [Provider Group National Provider ID] else [Provider National Provider ID] endif8Z"Arialn @/$@x&1?Mb?if [Primary Insurance Name] = "FL MEDICAID" then "1D" elseif [Referring Physician Insurance Code 1] <> "" then "1G" else "" endif;Z"Arial/$ @/$@tV?Mb?if [Primary Insurance Name] = "FL MEDICAID" then [Referring Physician Insurance Code 2] else [Referring Physician Insurance Code 1] endif)Z"Arialn@K7A$@?㥛 ?if [Primary Insurance Practice ID] = "" then [Primary Insurance Provider ID] else [Primary Insurance Practice ID] endif Z"Arial@n#@tV@K7A`?if [Claim Detail - Place of Service] = "11" then [Practice Name] else [Facility Name] endif]Z"Arial@K7A#@tV@K7A`?if [Claim Detail - Place of Service] = "11" then [Provider Address Line 1] " " [Provider Address Line 2] else [Facility Address Line 1] " " [Facility Address Line 2] endifgZ"ArialGz@㥛 0$@tV@K7A`?if [Claim Detail - Place of Service] = "11" then [Provider City] " " [Provider State] " " [Provider Zip Code] else [Facility City] " " [Facility State] " " [Facility Zip Code] endifZ"Arialsh|?@v$@?㥛 ?if [Claim Detail - Place of Service] <> "11" then [Facility ID 2] else "" endifZ"ArialQ@v$@?㥛 ?if [Claim Detail - Place of Service] <> "11" then [Facility National Provider ID] else "" endifZ"ArialDl @v$@MbX?㥛 ?if [Claim Detail - Place of Service] <> "11" then [Primary Insurance Provider ID Qualifier] else "" endif