1

Block

Commercial
Insurance

BCBS

Medicare

Medicaid

Tricare

Worker's Comp

x - other for ind/family plan

x - group plan

1A

ID #

4
5
6
7
8
9
10
11
12

13

Pt's name LAST, FIRST, MI

Pt's birth date MM DD YYYY &
X-gender
3
Policy holder's Last Name,
First Name, Initial
4
Pt's Address and Phone #
5
Pt's relationship to
policyholder, mark w/X
6
Policyholder's Address &
Phone#
7
LEAVE blank, NCCU.
8
9, 9A, 9D Other insurance name
9B-9C Leave blank.
X for Pt condition related to
auto, employment, or
10A-C accident.

X- Medicare box

X- Medicaid

X-TRICARE/CHAMPUS

BCBS 2nd payer

X-IN FECA DEFC OR XOTHER

Medicare 2nd payer

Medicaid 2nd payer

Tricare 2nd payer

X- Medicare & other

2ND or the
PATIENT SOCAIL SECURITY supplemental BCBS #

secondary policyholder

14

10D

15
16

11
11A

17

11B

18

11C

19
20
21

11D
12
13

22

14

23

15

24

16

25
26

17
17A

27

17B

28
29
30

18
19
20

31
32
33

21
22
23

34
35
36

24A
24B
24C

37

24D

38

24E

39
40

24F
24G

41
42

24h
24I

43
44
45

24J
25
26

Leave blank.
policy holders commercial
group number
policy holders DOB
Leave blank, workers comp.
claim
NAME policy holders
commercial insurance plan
X-if no 2nd insurance
coverage
enter signature on file (SOF)
SOF
Leave blank.
Date of S&S, QUAL 431 IF
PREGNANT 484
DATE PRIOR EPISODES OF
SAME ILLNESS
Leave blank.
Leave blank or DATE PT IS
UNABLE TO WORK
Leave blank.
Name of referring physician:
DN, DK, DQ.
Leave blank.
referring physician 10-digit
NPI
Hospital admission date &
discharge related to current
illness
LEAVE BLANK
X-no for outside labs
ICD-10-CM CODES, A-L, ICD
indicator "0"
LEAVE BLANK
Prior authorization numbers
FrM: DATE PROCEDURE
PERFORMED TO: IF
PROCEDURE PERFORMED ON
CONSECUTIVE DAYS
PLACE OF SERVICE
LEAVE BLANK
Enter CPT or HCPCS level ll
and midifier
Enter diagnosis pointer from
Block21
Fee charge for ea. Reported
procedure from Block21
days or units
Leave blank. Reserved for
Medicare forms.
Leave blank.
Leave blank, unless provider is
a member of group practice
(NPI)
Providers EIN
Pt's account #

46
47

27
28

Accept assignment X-yes or no

Total charhges from block24.

48
49

29
30

50

31

51
52
53

32
32A
32B

54

33

55
56

33A
33B

Leave blank, enter amt. pt.

paid for service
Leave blank.
Leave blank.
Leave blank.
Provider's name & credentials,
date.
Providers name & address if
services provided at another
location
10-digit NPI
Leave blank.
Provider's billing name,
address, telephone #.
10-digit NPI of the billing
provider
Leave blank.

2nd policy holders

Leave blank.

Leave Blank.

EMPLOYER NAME

SAME- policy holder is patient

primary policy

X- patients relationship to
primary

pt relationship to primary
policyholder

SAME

primary policyholder

Leave blank.

Leave Blank.

X-OTHER

Leave blank.
Leave blank.
Leave blank.
Leave blank.

Leave Blank.
Leave Blank.

EMPLOYER'S ADDRESS

TRICARE as 2ndery
TRICARE as 2ndery

2nd policy holder

primary policy holder

primary policy holder

PRIMARY

10-A X- YES
IF DD FORM 2527
ATTACHED
2nd policy #
Enter NONE
Leave blank.

Leave Blank.
Leave Blank.

LEAVE BLANK
LEAVE BLANK

9-DIGIT FECA #
LEAVE BLANK

CLAIM # WC THIRD PARTY

NAME OF WORKERS
2ND BCBS insurance
COMPENSATION PAYER
plan
X-YES
LEAVE BLANK
LEAVE BLANK
LEAVE BLANK

Leave Blank.

LEAVE BLANK

Leave blank.

Leave Blank.

LEAVE BLANK

Leave blank.

Leave Blank.
Leave Blank.
Leave Blank.

Leave blank.

2nd policyholder

BLANK OR # group health plan

MM DD YYYY X-gender

BLANK OR rejection code: K,

L, M, N, Q, R, S

LEAVE BLANK
LEAVE BLANK
LEAVE BLANK

name of primary policy

insurance plan
X- NO BOX

LEAVE BLANK
X-YES

X-yes

Leave Blank.
Leave blank.

Leave Blank.
Leave Blank.

LEAVE BLANK

E-emergency or leave blank.

Reimbursment $
received from primary
payer

amount paid by other payer , primary payer $, attached

if payer denied enter 0 00
remitance advice received
from the primary payer