OMB NO 0938-0008-2026

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The document is a Medicare form for patients to request medical payment, requiring personal and insurance information. It includes instructions for completion, emphasizes the importance of accurate information to avoid legal penalties, and outlines the necessary details for submitting claims, including itemized bills from healthcare providers.

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Click ‘Get Form’ to open OMB NO 0938-0008 in the editor.
In Block 1, print your name as it appears on your Health Insurance Card (Last Name, First Name, Middle Name).
For Block 2, enter your Health Insurance Claim Number exactly as shown on your Medicare card and check the appropriate box for the patient’s sex.
In Block 3, provide your mailing address and telephone number. If this is a new address, check the corresponding box.
Describe the condition related to treatment in Block 4. Check 'Yes' or 'No' for employment-related questions in Blocks 4b and 4c.
Complete Block 5 if you have additional medical coverage. Provide details such as policy numbers and insurance names.
Sign and date the form in Block 6. If unable to sign, follow instructions for a witness signature.

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