Health Insurance Claim Form
Patient's Details
Patient's Name
*
First Name
Last Name
Patient's Birth Date
*
-
Month
-
Day
Year
Date
Patient's Sex
Female
Male
Patient's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Phone Number
*
-
Area Code
Phone Number
Patient's Relationship to Insured
*
Self
Spouse
Child
Other
Patient's Status
Single
Married
Employed
Full Time Student
Part Time Student
Other
Is Patient's Condition Related To
Employment?
Yes
No
Auto Accident?
Yes
No
Other Accident?
Yes
No
Date of Signature
*
-
Month
-
Day
Year
Date
Patient's or Authorized Person's Signature
*
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Insured's Details
Insured's I.D. Number
*
Insured's Policy Group or FECA Number
*
Insured's Name
*
First Name
Last Name
Insured's Birth Date
*
-
Month
-
Day
Year
Date
Insured's Sex
Female
Male
Insured's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insured's Phone Number
*
-
Area Code
Phone Number
Insurance Plan Name or Program Name
*
Is There Another Health Benefit Plan?
*
Yes
No
Other Insured's Name
First Name
Last Name
Other Insured's Policy Group or FECA Number
Other Insured's Birth Date
-
Month
-
Day
Year
Date
Other Insured's Sex
Female
Male
Other Insurance Plan Name or Program Name
*
Date of Signature
*
-
Month
-
Day
Year
Date
Insured's or Authorized Person's Signature
*
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Illness/Injury Details
Date of Illness (First Symptom) or Injury (Accident) or Pregnancy (LMP)
-
Month
-
Day
Year
Date
If Patient Has Had Same or Similar Illness
-
Month
-
Day
Year
Date
Dates Patient Unable to Work in Current Occupation
Hospitalization Dates Related to Current Services
Diagnosis of Illness or Injury
*
1
Rows
Date(s) of Service To
Date(s) of Service From
Place of Service
EMG
Procedures, Services or Supplies
Diagnosis Pointer
$ Charges
Rendering Provider ID. #
1
2
3
4
5
6
Date of Signature
*
-
Month
-
Day
Year
Date
Signature of Physician or Supplier Including Degrees or Credentials
*
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Billing Details
Federal Tax I.D. Number
*
SSN
EIN
Patient's Account No
*
Total Charge
*
Amount Paid
*
Balance Due
*
Billing Provider Info & PH #
Submit
Should be Empty: