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Get NM CMS-1500 2005

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA 1. MEDICARE MEDICAID (Medicare #) (Medicaid #) TRICARE CHAMPUS (Sponsorʼs SSN) CHAMPVA (Member ID #) 2. PATIENTʼS NAME (Last Name, First Name, Middle Initial) 3. PATIENTʼS BIRTH DATE MM DD YY Header OTHER 1a. INSUREDʼS I.D. NUMBER FECA BLK LUNG (SSN) GROUP HEALTH PLAN (SSN or ID) (ID) SEX M F 6. PATIENT RELATIONSHIP TO INSURED 5. PATIENTʼS ADDRESS (No., Street) • Barcode removed. • “PLEASE DO NOT STAPLE IN T.

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