Get 1500 form 2012-2017

Description of 1500 claim form
PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 02-12 CARRIER HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE NUCC 02/12 PICA MEDICAID TRICARE ID /DoD GROUP HEALTH PLAN ID CHAMPVA Medicaid Member ID FECA BLK LUNG 3. AUTO ACCIDENT PLACE State c. OTHER ACCIDENT c. INSURANCE PLAN NAME OR PROGRAM NAME NO YES 10d. CLAIM CODES Designated by NUCC d. IS THERE ANOTHER HEALTH BENEFIT PLAN READ...
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1500 form
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CMS 1500 Form Versions

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CMS 1500 2012 4.8 Satisfied
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CMS 1500 2005 4.4 Satisfied
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