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Get DoL OWCP-1500 2012

NDERING PROVIDER ID. # NPI NPI 3 NPI 4 NPI 5 NPI 6 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. pp 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) SIGNED PATIENT AND INSURED INFORMATION MEDICARE DATE NUCC Instruction Manual available at: www.nucc.org 27. ACCEPT ASSIGNMENT? (For govt. claims, see back) p YES p NO 32. SERVICE FACILITY LOCATION.

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