Use the following scenario, please review the following 1500 form for to ensure filled out completel
Use the following scenario, please review the following 1500 form for to ensure filled out completely. Scenario:Patient Information Guarantor’s InformationJazmyn Grover Kim Carlson (Mom)210 Archer Way 210 Archer WayPort Snead, XY 12345-6789 Port Snead, XY 12345-6789DOB: 5/01/xx DOB: 7/30/xxSex: F Status: FT student Sex: FCondition not related to employment or accident Phone: 555-123-4567 Insurance Information Claim InformationCarrier: Blue Cross/ Blue Shield Referring MD: Joseph Wright, MDPolicy#: 75621483 Referring MD NPI: 1023459876Group#: 987456 Outside Lab: NoInsured: Kim Carlson DOS: 8-22-xxProcedures: 99212 (office visit) $65.00 POS: 11 (office) 87081 (throat culture) $25.00 Provider: Alexis Whalen, MD 85025 (CBC) $40.00 Provider NPI: 98876543210Diagnosis: J02.0 (Strep throat) Application 1 Information ( block 25-27 and 31-33)25. 22519813 31. Alexis Whalen26. VAA00255 32. 27. Yes 33. (555)654-3210 BWW MEDICAL ASSOCIATES 305 MAIN STREET PORT SNEAD XY 12345-6789 NPI: 1962410233Image transcription textHEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC)02/12 -CARRIER PICA MEDICARE MEDICAID TRICARE PICA (Medicares) (Medicaids) (DR/DOD!) CHAMPVAPATIENT’S NAME (Last Name. First Name, Middle Initial) (Member 10) (102) HEALTH PLAN UN X … Show more… Show more Health Science Science Nursing Share QuestionEmailCopy link Comments (0)
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