claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
claimform,"APPROVED OMB-0938-0008
PLEASE
DO NOT
STAPLE
IN THIS
AREA
PICA
HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE
MEDICAID
CHAMPUS
CHAMPVA
GROUP
FECA
OTHER
1a. INSURED'S I.D. NUMBER
(FOR PROGRAM IN ITEM 1)
HEALTH PLAN
BLK LUNG
X
(Medicare #)
(Medicaid #)
(Sponsor's SSN)
(VA File #)
(SSN or ID)
(SSN)
(ID)
11-2234-10190
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
3. PATIENT'S BIRTH DATE
MM
DD
YY
SEX
4. INSURED'S NAME (Last Name, First Name, Middle Initial)
Doe, John
M
F
Doe, Jane
5. PATIENT'S ADDRESS (No., Street)
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED'S ADDRESS (No., Street)
123 Any Street
Self
Spouse
X
Child
Other
123 Any Street
CITY
STATE
8. PATIENT STATUS
CITY
STATE
Any City
CA
Single
Married
Other
Any City
CA
ZIP CODE
TELEPHONE (Include Area Code)
ZIP CODE
TELEPHONE (INCLUDE AREA CODE)
( 858 ) 555-0100
Employed
Full-Time
Part-Time
92127
Student
Student
92127
( 858 ) 555-0100
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER
G4683A
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
a. INSURED'S DATE OF BIRTH
SEX
MM
DD
YY
YES
X
NO
M
F
06
12
65
b. OTHER INSURED'S DATE OF BIRTH
SEX
b. AUTO ACCIDENT?
PLACE (State)
b. EMPLOYER'S NAME OR SCHOOL NAME
MM
DD
YY
M
F
YES
X
NO
AND
C. EMPLOYER'S NAME OR SCHOOL NAME
C. OTHER ACCIDENT?
C. INSURANCE PLAN NAME OR PROGRAM NAME
YES
NO
Group Insur of Amer.
PATIENT
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. RESERVED FOR LOCAL USE
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
X
NO
If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
services described below.
below.
Jdoe
SIGNED
DATE 01-15-2021
JaneDoe
SIGNED
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM
DD
YY
INJURY (Accident) OR
GIVE FIRST DATE MM
DD
YY
MM
DD
YY
MM
DD
YY
10
11
21
PREGNANCY(LMP)
10
11
21
FROM
TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17a. I.D. NUMBER OF REFERRING PHYSICIAN
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
Self
FROM
TO
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
R11 0
R19 7
1.
3.
23. PRIOR AUTHORIZATION NUMBER
2.
K59 00
4.
K92 1
24.
A
B
C
D
E
F
G
H
J
K
DATE(S) OF SERVICE
Place
Type
PROCEDURES, SERVICES, OR SUPPLIES
DAYS
EPSDT
From
To
DIAGNOSIS
RESERVED FOR
of
of
(Explain Unusual Circumstances)
OR
CODE
$ CHARGES
Family
EMG
COB
LOCAL USE
MM
DD
YY
MM
DD
YY
Service
Service
CPT/HCPCS
MODIFIER
UNITS
Plan
10
11
21
11
90801
170.00
1234567890
1
10
11
21
11
90805
140.00
1234567890
2
10
11
21
11
90812
93
00
1234567890
SUPPLIER
3
4
5
6
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. BALANCE DUE
(For govt. claims, see back)
555-88-9999
X
YES
NO
$
405
.00
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
33. PHYSICIAN'S SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
RENDERED (If other than home or office)
& PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
Mateo Jackson PhD
Mateo Jackson PhD
9876 Healthcare Ave
9876 Healthcare Ave
(920) 555-0101
MtJackson
10/11/21
Any Town, CA 92126
Any Town, CA 92126
SIGNED
DATE
PIN#
GRP#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
FORM HCFA-1500 (12-90), ORMRRB-1500,
FORM OWCP-1500
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
doctorsnote,"Attending Provider Notes
Provider: Dr Mateo Jackson, PhD
Patient: John Doe
35 yo M c/o stomach problems since last 2 months. Patient reports epigastric abdominal pain
non-radiating. Pain is described as gnawing and burning, intermittent lasting 1-2 hours, and
gotten progressively worse. Antacids used to alleviate pain but not anymore; nothing
exacerbates pain. Pain unrelated to daytime or to meals. Patient denies constipation or
diarrhea. Patient denies blood in stool but have noticed them darker. Patient also reports
nausea. Denies recent illness or fever. He also reports fatigue in the last 2 weeks ago and
bloating after eating.
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHx: Back pain and muscle spasms. No Hx of surgery.
NKDA.
FHx: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPI
3. Denies illicit drug use. Works on
high elevation construction. Fast food diet. Exercises 3-4 times/week but stopped 2 weeks ago.
Mateo Jackson
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"
dischargesummary,"Not a Memorial Hospital
Of Collier
Reg: PN/S/11011. Non-Profit
Contact (999)-(888)-(1234)
Physician Hospital Discharge Summary
Provider: Mateo Jackson, Phd
Patient: John Doe
Provider's Pt ID: 00988277891
Patient Gender: Male
Attachment Control Number: XA/7B/00338763
Visit (Encounter)
Admitted: 07-Sep-2020
Discharged: 08-Sep-2020
Discharged to: Home with support services
Assessment
Reported Symptoms / History
35 yo M c/o stomach problems since 2 montsh ago. Patient
reports epigastric abdominal pain non-radiating. Pain is
of present illness:
described as gnawing and burning, intermitent lasting 1-2
hours and gotten progressively worse. Antacids used to
alleviate pain but not anymore; nothing exhacerbates pain.
Pain unrelated to daytime or to meals. Patient denies
constipation or diarrhea. Patient denies blood in stool but
have noticed them darker. Patient also reports nausea.
Denies recent illness or fever. He also reports fatigue
since 2 weeks ago and bloating after eating.
Patient ID: NARH-36640
ROS: Negative except for above findings
Meds: Motrin once/week. Tums previously.
PMHX: Back pain and muscle spasms. No Hx of surgery. NKDA.
FHX: Uncle has a bleeding ulcer.
Social Hx: Smokes since 15 yo, 1/2-1 PPD. NO recent EtOH
use. Denies illicit drug use. works on high elevation
construction. Fast food diet. Exercises 3-4 times/week but
stopped 2 weeks ago.
Discharge
Discharge Studies Summary:
Some activity restrictions suggested, full course of
antibiotics, check back with physican in case of relapse,
strict diet
VS/3S/Q990-7550/1090001004290
"