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wk 4

Box 1 Type of insurance
Box 2 Patient name
Box 3 Patient Birthday and gender
Box 4 Insureds name
Box 1a Insureds ID #
Box 5 Patients address
Box 6 Patient relationship to insured
Box 7 Insureds address
Box 8 Reserved for NUCC use
Box 9 and a-d Other insureds name a. Other insureds policy or grp # b. Reserved for NUCC use c. Reserved for NUCC use d. Insurance plan name or program name
Box 10 and 10d Is patients condition related to 10d claims codes
Box 11 Insureds policy grp or feca #
Box 12 Patient or authorized person signature
Box 13 Insureds or authorized persons signature
Box 14 Date of current illness
Box 15 Other date
Box 16 Dates patient unable to wrk in current occupation
Box 17 Name of referrering provider or other source
Box 18 Hospitalization dates related to current services
Box 19 Additional claim information
Box 20 Outside labs
Box 21 ICD-10 codes diagnosis or nature of illness or injury
Box 22 Resubmission code
Box 23 Prior authorization number
Box 24a-j 24a dates of service b. Place of service c. Emg d. Cpt/hcpcs....modifier procedure, services, or supplies e. Diagnosis pointer f. Charges g. Days or units h. East family plan I. ID qual/npi j. Rendering provider
Box 25 Federal tax id number
Box 26 Patients account #
Box 27 Accept assignment
Box 28 Total charge
Box 29 Amount paid
Box 30 Reserved for NUCC use
Box 31 Dr. Signature
Box 32 Service facility location information
Box 33 Billing provider info and phone #
Created by: cheri le