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Accuracy is important. This form may be downloaded at http //www. ime. state. ia*us/Providers/index. html MEMBER INFORMATION STATE ID MEMBER S NAME LAST FIRST MI PROVIDER INFORMATION NPI PROVIDER NUMBER PROVIDER ADDRESS NAME STREET CITY STATE ZIP CODE OTHER INSURANCE IF NO LEAVE BLANK TAXONOMY CODE YES SERVICES A. B. C. D. PROCEDURE CODE PLACE OF FIRST DATE LAST DATE MM/DD/YY E* F* UNITS TOTAL LINE CHARGE TOTAL CLAIM CHARGES CLIENT PARTICIPATION AMOUNT THIRD PARTY PAYMENT PLACE OF SERVICE REFER ...

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