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  • 2 22 89 Claim Form

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    OKTeaPartyPAC
    8 tayangan1 halaman
    HEALTH INSURANCE CLAIM' FORM (CHECK APPLICABLE 'PROGRAM BLOCK BELOW) PLEASE DO NOT' PATIENT'S NAME (lAST NAME, FIRST NAME, MIDDLE INITIAL) pL SO. 8. INSURED'S GROUP NO. IDR GROUP NAME DR FECI. CLAIM NO.) AND COVERED BY EMPlOYER THROUGH GIVE

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    HEALTH INSURANCE CLAIM' FORM (CHECK APPLICABLE 'PROGRAM BLOCK BELOW) PLEASE DO NOT' PATIENT'S NAME (lAST NAME, FIRST NAME, MIDDLE INITIAL) pL SO. 8. INSURED'S GROUP NO. IDR GROUP NAME DR FECI. CLAIM NO.) AND COVERED BY EMPlOYER THROUGH GIVE

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    Attribution Non-Commercial (BY-NC)
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    8 tayangan1 halaman

    2 22 89 Claim Form

    Diunggah oleh

    OKTeaPartyPAC
    HEALTH INSURANCE CLAIM' FORM (CHECK APPLICABLE 'PROGRAM BLOCK BELOW) PLEASE DO NOT' PATIENT'S NAME (lAST NAME, FIRST NAME, MIDDLE INITIAL) pL SO. 8. INSURED'S GROUP NO. IDR GROUP NAME DR FECI. CLAIM NO.) AND COVERED BY EMPlOYER THROUGH GIVE

    Hak Cipta:

    Attribution Non-Commercial (BY-NC)
    Unduh sebagai PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 1

    PLEASE DO NOT'

    It"A'L& n~l[ S 'lR"el!!rll~.IIIiICll':!:U' N


    THIS'AREA

    :f

    PATIENT'S NAME (lAST NAME, FIRST NAME, MIDDLE INITIAL)

    T, SHARP SHERIDAN S. BOSTON 700 KENNEDY SA OK 74108

    .~

    HEALTH INSURANCE CLAIM' FORM


    (CHECK APPLICABLE 'PROGRAM BLOCK BELOW)

    'FORM APPR'OVED OMB NO, EI938-OOO8

    SULLIVAN,
    4.'

    DANIEL S~'
    117

    PATIENT'S ADDRESS (STIIEE1; CITY, 'STATE, ZIP CODE)

    10006

    E.

    pL SO.

    BIXBY

    m{

    7.40-OfJ ...

    4447284.,86 L.!:iB045

    8. INSURED'S GROUP NO. IDR GROUP NAME DR FECI. CLAIM NO.)

    AND COVERED BY EMPlOYER

    DND
    d
    OTHER

    THROUGH GIVE
    "

    21.

    NAME AND ADDRESS OF fAClUTY

    WHERE SERVICES RENDERED (IF OTHER THAN HOME DR OFFICE) CHARGES:

    EPSDT 2. 3, 4, 24. DATE o~sEilVlCE FROM TO PRIOR , AUTHORIZATION NO. FAMILY PLANNING

    YESO' YESO

    rjNO

    ONO

    02/~:~O/89 ..

    s
    ,!i
    0..

    s w
    Q

    a:

    s
    in

    ~ ~

    F
    DATE: 32. YOUR PATIENT'S ACCOUNT NO.

    FEB
    OBOO('.
    PAGE 0t OF
    APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 6/83

    ~~

    SUITE 208 TULSA

    OK 74104
    918-747-456

    ~ ,...

    -PlACE OF SERVICE AND TYPE OF REMARKS:

    Form HCFA-1500 (C-2) (1-84) Form OWCP-1500 Form CHAMPUS-501 Form RRB-1500
    J

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