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Please help me I am so lost..thank you!?

Complete a CMS-1500 Claim Form If you believe information provided in the following list is insufficient to adequately fill a required field with data, for example, to supply a specific diagnosis code, indicate this by typing N/A. If no patient information has been given for a specific field, leave it blank. Name: Katherine Doe Insurer: TRICARE Policy Number: 123456 ID number: 999000666 DOB: 01/01/1950 Gender: Female Insured: James Doe, spouse Address: 1111 Noname Court, Nowhere, NY 22222 Marital Status: Married Patient’s Employer: Homemaker Spouse’s Employer: U.S. Army Nature of Condition: Routine exam Patient Signature Appendix C 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER CHAMPUS HEALTH PLAN BLK LUNG (Medicare #) (Medicaid #) (Sponsor’s SSN) (Member ID #) (SSN or ID) (SSN) (ID) 1a. INSURED’S I.D. # (For Program in Item 1) 3. PATIENT’S BIRTH DATE SEX 2. PATIENT’S NAME (Last Name, First Name, MI) MM DD YY M F 4. INSURED’S NAME (Last Name, First Name, MI) 5. PATIENT’S ADDRESS ( #, Street) 6. PATIENT RELATIONSHIP TO INSURED Self Spouse Child Other 7. INSURED’S ADDRESS ( #, Street) CITY STATE CITY STATE ZIP CODE TELEPHONE (Include Area Code) ( ) 8. PATIENT STATUS Single Married Other Employed Full-Time Part-Time Student Student ZIP CODE TELEPHONE (Include Area Code) ( ) 9. OTHER INSURED’S NAME (Last Name, First Name, MI) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA # a. INSURED’S DATE OF BIRTH SEX a. OTHER INSURED’S POLICY OR GROUP # a. EMPLOYMENT? (Current of Previous) YES NO MM DD YY M F b. INSURED’S DATE OF BIRTH SEX PLACE (State) MM DD YY M F b. AUTO ACCIDENT? YES NO b. EMPLOYER’S NAME OR SCHOOL NAME c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? YES NO c. INSURANCE PLAN NAME OR PROGRAM NAME d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. LOCAL USE d. HEALTH BENEFIT PLAN? YES NO If yes, return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENTS OR AUTHORIZED PERSON’S SIGNATURE SIGNED DATE . 13. INSUREDS OR AUTHORIZED PERSON’S SIGNATURE SIGNED . 14. DATE OF CURRENT: 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP) GIVE FIRST DATE MM DD YY MM FROM DD YY MM TO DD YY 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 17a. 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17b. NPI MM FROM DD YY MM TO DD YY 20. OUTSIDE LAB? $CHARGES 19. RESERVED FOR LOCAL USE YES NO 22. MEDICADE RESUBMISSION CODE ORIGINAL REF. # 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. | . . 3. | . . 2. | . . 4. | . . 23. PRIOR AUTHORIZATION # D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) 24. A. DATE(S) OF SERVICE From To MM DD YY MM DD YY B. PLACE OF SERVICE C. EMG CPT/HCPCS MODIFIER E. DIAGNOSIS POINTER (1, 2, 3, or 4) F. $ CHARGES G. DAYS OR UNITS H. EPSDT Family Plan I. ID. QUAL. J. PROVIDER ID. # NPI NPI NPI NPI 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE 27. ACCEPT ASSIGNMENT? (For govt. claims, see back) 25. FEDERAL TAX I.D. # SSN EIN 26. PATIENT’S ACCOUNT # YES NO $ $ $ 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # ( ) 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS SIGNED DATE a. b. a.

Public Comments

1. your question is too long and confusing. good luck if anyone actually answers