Hcr220 Final Exam

Appendix C MEDICAID (Medicaid #) TRICARE CHAMPUS (Sponsors SSN) CHAMPVA GROUP HEALTH PLAN (SSN or ID) (Member ID #) 2. tolerantS NAME (Last Name, First Name, MI) 3. patientS BIRTH date MM DD YY Brown, James 01 02 5. PATIENTS ADDRESS ( #, Street) OTHER 1a. INSUREDS I.D. # CITY SEX M 4. INSUREDS NAME (Last Name, First Name, MI) F 40 7. INSUREDS ADDRESS ( #, Street) Self Spouse 8. PATIENT STATUS STATE D.C CITY WA Child Other Single Married Other Employed Full-Time Student Part-Time Student TELEPHONE (Include Area Code) ( 60000 ZIP CODE ) 9. OTHER INSUREDS NAME (Last Name, First Name, MI) ( 10. IS PATIENTS CONDITION related to TO: 11. INSUREDS POLICY GROUP OR FECA # a. betrothal? (Current of Previous) YES DD YY M MM b. AUTO ACCIDENT? SEX PLACE (State) YES F a. INSUREDS DATE OF BIRTH NO c. OTHER ACCIDENT? d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. LOCAL USE d. HEALTH BENEFIT PLAN? 08 01 unhealthiness (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP) 07 06 21. DIAGNOSIS OR NATURE OF unhealthiness OR INJURY AIDS . MM 3. | DATE(S) OF SERVICE From To DD YY MM 01 07 06 15 07 07 07 07 4. | B.

DD YY 08 01 EMG . 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO 20. OUTSIDE science lab? $CHARGES YES NO 22. MEDICADE RESUBMISSION CODE ORIGINAL REF. # . 23. PRIOR AUTHORIZATION # . D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER F. G. H. I. J. $ CHARGES E. DIAGNOSIS POINTER DAYS OR UNITS EPSDT Family Plan ID. QUAL. supplier ID. # (1, 2, 3, or 4) NPI Blood NPI 11 SSN EIN Exam 11 07 25. FEDERAL TAX I.D. # C. PLACE OF SERVICE . Signature on File... If you regard to get a full essay, order it on our website: Orderessay

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