Get DoL OWCP-1500 2015-2021
$ $ 30. Rsvd for NUCC Use (For govt. claims, see back) EIN 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.) 28. TOTAL CHARGE 32. SERVICE FACILITY LOCATION INFORMATION a. b. PLEASE PRINT OR TYPE No 33. BILLING PROVIDER INFO & PH # a. b. APPROVED OMB-093B-1197 FORM CMS-1500 (06-15) PHYSICIAN OR SUPPLIER INFORMATION NPI Instructions for Completing OWCP-1500 Healt.
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