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In today's video tutorial, we will learn how to complete a HICFA 1500 claim form. This form is used by non-institutional healthcare providers to submit their claims. Although most claims are submitted electronically, secondary claims are usually submitted on paper with the primary Electronic Data Interchange (ELB). The claim form is being sent to Edna, and the type of insurance in Box 1 is "other" as it is a commercial policy. We will fill in the member ID insured by D in Box 2, the patient's name in Box 3, and the patient's date of birth and gender in Box 3. Box 5 requires the patient's address and phone number, and Box 6 asks for the patient's relationship, which in this case is self. For this example, we will fill in Roxie's information as the patient is self-insured. In Box E, we need to specify the insurance plan name.