Get Owcp 1500 Printable Form

This guide provides clear and detailed instructions for filling out the Owcp 1500 Printable Form online. By following these steps, you can ensure that your health insurance claims are completed accurately and submitted without delays.

Follow the steps to accurately complete the Owcp 1500 Printable Form.

1. Press the ‘Get Form’ button to access the Owcp 1500 Printable Form and open it in your preferred form editor.
2. In Item 1, leave this field blank. Proceed to Item 1a where you will enter the patient's claim number.
3. For Item 2, fill in the patient's last name, first name, and middle initial.
4. In Item 3, enter the patient's birth date using the MM/DD/YY format and check the appropriate box indicating their sex.
5. Move to Item 4. If you are filing for a FECA claim, leave this blank. For BLBA or EEOICPA claims, enter the name of the party to whom the medical payment is due only if the patient is deceased.
6. In Item 5, provide the patient's complete address, which includes the street address, city, state, and ZIP code. The telephone number is optional.
7. Skip Item 6 and Item 7; they are not required for FECA claimants.
8. In Item 8, indicate the patient’s relationship to the insured by checking the relevant box.
9. For Items 9 to 10, enter the details of any other insured individuals if applicable, and respond to the question about the relationship of the patient’s condition to their employment.
10. In Item 11, enter the insured's policy group or FECA number. Ensure that all data entries are accurate to avoid processing delays.
11. In Item 12, provide the signature of the patient or an authorized person, which authorizes the release of medical information necessary for processing the claim.
12. Complete Item 18 and Item 19 with the hospitalization dates related to current services if applicable.
13. In Item 21, enter the diagnosis or nature of the illness or injury using appropriate ICD codes. Ensure this relates to the services listed and includes the primary and secondary conditions.
14. In Items 22 to 24, detail the services provided, including the date of service, place of service, CPT code, total charges, and any other required codes.
15. Finalize your form by completing Items 25 through 33, which include tax identification, total charge, signature of the physician or supplier, and billing provider information.
16. Once all required fields are filled, review the form for accuracy. You can then save your changes, download, print, or share the completed form as needed.

Start completing your Owcp 1500 Printable Form online today to ensure timely and accurate claim submission.