Home
Forms Library
69121-13 Doctors Office Claim Form indd

69121-13 Doctors Office Claim Form indd 2025

69121-13 Doctors Office Claim Form indd Preview on Page 1

See details

4.2 out of 5

60 votes

The document provides instructions for filing a claim for doctor's office visits and prescription drugs with Colonial Life & Accident Insurance Company. It includes details on how to submit claims via fax or online, the necessary information required, optional service agreements, and fraud warnings. Additionally, it outlines the authorization needed for the disclosure of health information in compliance with HIPAA regulations.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

The best way to edit 69121-13 Doctors Office Claim Form indd in PDF format online

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Adjusting paperwork with our comprehensive and user-friendly PDF editor is easy. Follow the instructions below to complete 69121-13 Doctors Office Claim Form indd online quickly and easily:

Log in to your account. Sign up with your credentials or create a free account to test the service before choosing the subscription.
Import a document. Drag and drop the file from your device or add it from other services, like Google Drive, OneDrive, Dropbox, or an external link.
Edit 69121-13 Doctors Office Claim Form indd. Quickly add and highlight text, insert pictures, checkmarks, and icons, drop new fillable fields, and rearrange or remove pages from your paperwork.
Get the 69121-13 Doctors Office Claim Form indd completed. Download your adjusted document, export it to the cloud, print it from the editor, or share it with other people using a Shareable link or as an email attachment.

Benefit from DocHub, the most straightforward editor to rapidly handle your paperwork online!

See more 69121-13 Doctors Office Claim Form indd versions

We've got more versions of the 69121-13 Doctors Office Claim Form indd form. Select the right 69121-13 Doctors Office Claim Form indd version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (89 Votes)
2020	4.4 Satisfied (87 Votes)
2018	4.2 Satisfied (60 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is a HCFA-1500 claim form?

A medical claim is an invoice (or bill) that is submitted by your doctors office to your health insurance company after you receive care. Each claim has a list of unique codes that describe the care you received and help your health plan process and pay them faster.

What claim form is used for physician claims?

However, the term HCFA is still commonly used to refer to the standard claim form used by healthcare providers to bill Medicare and some private insurance companies. The form is officially known as the HCFA-1500, but it is also sometimes called the CMS-1500 or simply the medical claim form.

What is a medical claim form?

In simpler terms, a medical claim form is a formal written request that a healthcare provider submits to an insurance company, Medicare or Medicaid, or another affiliated entity seeking compensation for the healthcare services provided to a patient.

What is a medical insurance claim form?

The UB-04 claim form is used to submit claims for outpatient services by institutional facilities (for example, outpatient departments, Rural Health Clinics and chronic dialysis centers).

Why did I get a health insurance claim form?

The CMS-1500 form is the official standard Medicare and Medicaid health insurance claim form required by the Centers for Medicare Medicaid Services (CMS) of the U.S. Department of Health Human Services.