Medical Claim Form (PDF) - Pebp.state.nv.us

Health Claim FormEmployees:1. Please complete items 1 through 8 in full.2. Please complete items 8 through 11 onlyif you have other medical coverage,including Medicare.3. Please be sure to sign the authorizationso we can release information on items12 and 13 if necessary.4. If you have submitted a request forbenefits under another health plan(including Medicare), please attach acopy of the bills you sent to the otherplan and the Explanation of Benefits formthe plan sent to you.Employee Information1. Employee’s SSN5. Attach itemized bills or ask your healthcare provider to complete the applicablesection. The bills must include:a. Patient’s nameb. Date(s) of servicec. Condition being treatedd. Relationship to employeee. Type of service(s) givenIf any of this information missing, simplywrite it on the bill and sign your name.6. Keep copies of your bills for your records.7. The mailing address for claims in on theback of your ID card. HealthSCOPEBenefits; P.O. Box 91603; Lubbock, TX794908. Patient StatusSingle Married Other11. Employee’s Policy/Group No.Group NumberNVPEB2. Patient’s Name (Last, First, Middle)3. Patient’s Date of Birth GenderM4. Employee’s Name (Last, First, Middle)FEmployed?Yes NoFull Time Student? Yes NoPart Time Student? Yes No9. Other Insured’s Name (Last, First, Middle)a. Other Insured’s Policy or Group No.b. Other Insured’s Date of Birtha. Employee’s Date of Birthb. Claims AdministratorHealthSCOPE BenefitsP. O. Box 91603Lubbock, TX 79490-1603email: pebp@healthscopebenefits.comwww.healthscopebenefits.comc. Is there another health benefit plan?(additional coverage)Yes No(If Yes, return to and complete item 9 a-d)5. Patient’s Addressc. Employer’s Name or School Name12: Patient’s or Authorized Person’s SignatureCityState/Zip6. Patient’s Relationship to EmployeeSelf Spouse Child Other7. Employee’s AddressCityState/Zipd. Insurance Plan Name or Program Name10. Is Patient’s Condition Related to:a. Employment? (Current or Previous)Yes Nob. Auto Accident?Yes Noc. Other Accident?Yes Nod. Please provide accident details:I authorize the release of any medical orother information necessary to process thisclaim. I also request payment of governmentbenefits either to myself or to the party whoaccepts assignment below.SignedDate13: Authorized Person’s SignatureI authorize payment of medical benefits tothe undersigned physician or supplier forservices described below.SignedDatePhysician and supplier form on reverse side...

Physician or Supplier Information14. Date of Current Illness (First Symptoms)or Injury (Accident) or Pregnancy (LMP)15. If Patient has had Same or Similar IllnessGive First Date16. Date Patient Unable to Work in CurrentConditionFrom:To:17. Name of Referring Physician or otherSource18. I.D. No. Of Referring Physician19. Hospital Dates Related to Current ServicesFrom:20. Outside Lab? $ ChargesYesNoTo:21. Diagnosis or Nature of Illness or Injury(Relate Items 1,2,3 or 4 to Item 24E by line)123422. Medicaid Resubmission23. Prior Authorization Number24. A B C D E F G H I JDates of ServicesTo FromPlace ofServiceType ofServiceProcedures, Service, or Supplies(Explain Unusual Circumstances)CPT HCPCS ModifierDiagnosisCodeChargesDays orUnitsEPSOTFamPlanEMGCOB12345625.Fed Tax IDSSNEIN26. Patient Account Number27. Accept Assignment?Yes No28. Total Charge29. Amount Paid32. Name and Address of Facility WhereServices Were RenderedNameCityState/Zip33. Physician/Supplier Billing Address:CityState/ZipPhysician or Supplier:1. Complete items 14 through 33in full.2. If the employee indicatesbenefits should be paid directlyto you, then these benefits willbe sent directly to you and aninformational copy of thetransaction will be sent to theemployee.PIN #GRP#30. Balance Due31. Signature of Physician or SupplierSignedDate