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How to use or fill out IMPORTANT: PLEASE READ THE ATTACHED INSTRUCTIONS PRIOR TO SUBMITTING A CLAIM TO MEDICARE with DocHub
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Click ‘Get Form’ to open it in the editor.
Begin by filling out Section 1 - PATIENT INFORMATION. Enter your name as shown on your Medicare card, your Medicare number, date of birth, gender, address, and telephone number.
Proceed to Section 2 - INFORMATION ABOUT SERVICES FURNISHED. Describe the illness or injury for which you received treatment and attach an itemized bill that includes all required details such as date of service and provider information.
In Section 3 - INFORMATION ABOUT HEALTH INSURANCE OTHER THAN MEDICARE, complete this section if applicable. Provide details about any other medical coverage you may have.
Finally, sign and date the form in Section 4 - SIGNATURE. If you cannot sign, follow the instructions provided for marking an 'X' and having a witness sign.
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