Patient name (last name, first name, Middle initial)

Insurance name (last name, first name, middle initial)

Patient address , city, state , zip code, Telephone

Patient relationship to insured

Insurance address , city, state, zip code, telephone

other insured name (last name, first name, middle initial)

Other insured policy or group number

Insurance plan name or program name

is the patient condition related to

insurance policy group of feca number

insurance plan name or program name

patient or authorized person signature

insurance or authorized person signature

dates of current illness, injury pregnancy

hospital date related to current service

diagnosis or nature of illness or injury

Signature of physician or supplier includes degrees credential

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Question	Answer
Block1.	Medicare box
Block1a	Insurance ID number
Block2.	Patient name (last name, first name, Middle initial)
Block3.	patient birth date/sex
Block4.	Insurance name (last name, first name, middle initial)
Block5	Patient address , city, state , zip code, Telephone
Block6.	Patient relationship to insured
Block7.	Insurance address , city, state, zip code, telephone
Block8.	Reserved for Nucc use
Block9.	other insured name (last name, first name, middle initial)
block9a.	Other insured policy or group number
block9b.	Reserved for NUCC use
block9c.	Reserved for NUCC use
block9d.	Insurance plan name or program name
Block10	is the patient condition related to
Block10a	employment
Block10b	auto accident
Block10c	other accident
Block10d
Block11	insurance policy group of feca number
Block11a	insurance date of birth / sex
Block11b	other claim
Block11c	insurance plan name or program name
Block11d	another health benefits plan
Block12	patient or authorized person signature
Block13	insurance or authorized person signature
Block14	dates of current illness, injury pregnancy
Block15	other date
Block16	dates patent unable to work
Block17	leave blank
Block18	hospital date related to current service
Block19	leave blank
Block20
Block21	diagnosis or nature of illness or injury
Block22	Resubmission number
Block23	Prior authorization number
Block24a	dates of service
Block24b	place of service
Block24c	Emg
Block24d	Procedures service or supplies
Block24e	Diagnosis pointer
Block24f	$ charges
Block24G	Days or units
Block24H	EPSDT
Block24I	ID qual
Block24J	Rendering provider ID
Block25	Federal Tax I.d number
Block26	patients account NO.
Block27	accept assignment
Block28	total charge
Block29	amount paid
Block30	Rsvd for Nucc use
Block31	Signature of physician or supplier includes degrees credential
Block32	service facility location information
Block33	Billing provider information & ph #

Created by: Jackie_20

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