Hcr 220 Appendix C

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Appendix C
1. MEDICARE (Medicare #) MEDICAID (Medicaid #) TRICARE CHAMPUS (Sponsor’s SSN) CHAMPVA (Member ID #) GROUP HEALTH PLAN (SSN or ID) FECA BLK LUNG (SSN) OTHER (ID) SEX M 1a. INSURED’S I.D. # (For Program in Item 1)

12345678910
4. INSURED’S NAME (Last Name, First Name, MI) F

2. PATIENT’S NAME (Last Name, First Name, MI)

Jones, Davie
5. PATIENT’S ADDRESS ( #, Street)

3. PATIENT’S BIRTH DATE MM DD YY

02

01

1940
Child Other

Jones, Davie
7. INSURED’S ADDRESS ( #, Street)

6. PATIENT RELATIONSHIP TO INSURED Self Spouse 8. PATIENT STATUS Single Employed

CITY

STATE

PH O EN
CITY

1600 Pennsylvania Avenue
Wash
ZIP CODE

1600 Pennsylvania Avenue

DC
TELEPHONE (Include Area Code)

Married Full-Time Student

Other

Wash

ZIP CODE

TELEPHONE (Include Area Code)

60000

(

)

Part-Time Student

60000

(

9. OTHER INSURED’S NAME (Last Name, First Name, MI)

10. IS PATIENT’S CONDITION RELATED TO:

11. INSURED’S POLICY GROUP OR FECA #

1098765

a. OTHER INSURED’S POLICY OR GROUP #

a. EMPLOYMENT? (Current of Previous) YES NO

a. INSURED’S DATE OF BIRTH

02

MM

01

DD

1940

YY

M

b. INSURED’S DATE OF BIRTH MM DD YY M c. EMPLOYER’S NAME OR SCHOOL NAME

SEX F

b. AUTO ACCIDENT? YES c. OTHER ACCIDENT? YES 10d. LOCAL USE NO NO

PLACE (State)

b. EMPLOYER’S NAME OR SCHOOL NAME

Retired

c. INSURANCE PLAN NAME OR PROGRAM NAME

Retired
d. INSURANCE PLAN NAME OR PROGRAM NAME

d. HEALTH BENEFIT PLAN? YES NO

If yes, return to and complete item 9 a-d.

14. DATE OF CURRENT: MM DD YY

05

01

2011

ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP)

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM DD YY

O

SIGNED

Signature on File

F

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENTS OR…...

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