Health Insurance Claim Form Nucc Pdf

Insurance plan name or program name yes.

Health insurance claim form nucc pdf. The uniform claim form task force was replaced by the national uniform claim committee nucc in the mid 1990s. Health insurance claim form approved by national uniform claim committee nucc 02 12 for program in item 1 medicare medicaid id dod member id id id id 1. Download form cms 1500 instruction manual only the latest version of the original manual from the national uniform claim comettee of how to complete the claim form 1500. Download the fillable hcfa 1500 claim form that is both a fillable and or printable medical claim form that will provide insurance illness and injury information for medical services claims if the user would like to complete the form online simply download click inside the box to begin and begin typing your information.

Use of the version 02 12 1500 claim form went into effect april 1 2014. The form image may not print to scale. In the 1960s there were a number of different claim forms and coding systems required by third party payers. This image of the form should not be used for claims submission.

Patient s or authorized person s signature i authorize the release of any medical or other information necessary to. The nucc has developed a 1500 reference instruction manual detailing how to complete the claim form. Other claim id designated by nucc c. Read back of form before completing signing this form.

Is there another health benefit plan. Download nucc claim form cms 1500 02 12 fillable pdf template. Read the instructions below first. Free pdf template download.

1500 claim form 1500 claim form 02 12 version. The following is the pdf of the revised 1500 form including the template and grid versions. The 1500 health insurance claim form answers the needs of many health payers. The current version of the instructions for the 02 12 1500 claim form was released in.

Insured s id number 2. Yes complete items 9 9a and 9d. Medicare medicaid tricare champva group health plan feca blk lung other 1a. It is the basic paper claim form prescribed by many health plans for claims submitted by physicians and suppliers and in some cases for ambulance services.

1500 claim form reference instruction manual.