Get Mayo Clinic Understanding Your HCFA 1500 Claim Form 1990-2023
Ther 8. PATIENT STATUS STATE Single ZIP CODE 4. INSURED’S NAME (Last Name, First Name, Middle Initial) SEX M Self CITY Married ZIP CODE 9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) Full-Time Part-Time Student Student 10. IS PATIENT’S CONDITION RELATED TO: a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) TELEPHONE (INCLUDE AREA CODE) ( Employed ) YES b. OTHER INSURED’S DATE OF BIRTH MM DD YY STATE Other TELEPHONE (Inc.
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