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Form health claimDocHubcom 2012-2019-2026

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4.4 out of 5

541 votes

The document is a Health Insurance Claim Form (OWCP-1500) used for submitting medical claims under various federal programs, including the Federal Employees' Compensation Act (FECA), Black Lung Benefits Act (BLBA), and Energy Employees Occupational Illness Compensation Program Act (EEOICPA). It outlines the necessary patient and insured information, procedures for completing the form, and guidelines for billing providers. The form requires detailed information about the patient's condition, treatment dates, diagnosis codes, and provider signatures to ensure proper processing and payment of claims.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's name in Item 2, including last name, first name, and middle initial.
In Item 3, input the patient's birth date (MM/DD/YY) and select the appropriate box for their sex.
Fill in Item 5 with the patient's address, including street number, city, state, and ZIP code. Telephone number is optional.
For Item 11, enter the patient's claim number if applicable; this is crucial for processing.
In Item 21, provide diagnosis codes using current ICD codes. Ensure they are listed in priority order.
Complete Items 24A through 24J with service dates, place of service codes, CPT codes, and total charges for each service provided.
Finally, ensure all required signatures are completed in Items 12 and 31 before submitting your form.

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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (191 Votes)
2012	4.4 Satisfied (541 Votes)
2006	4 Satisfied (42 Votes)

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