Health Insurance Claim Form (CMS 1500)

Practice Manager **Health Insurance Claim Form** **1. Type of Service:** Medical Consultation **2. Date of Service:** 1 November 2024 **3. Patient Information:** * **Full Name:** Sarah Elizabeth Jenkins * **Date of Birth:** 15 May 1990 * **Address:** 14 Willow Creek Lane, Brighton, BN1 4GH * **Contact Number:** 07700 900321 * **Insurance Policy Number:** ABC123456789 **4. Provider Information:** * **Provider Name:** Dr. Eleanor Vance, GP * **Clinic Name:** Brighton Family Practice * **Clinic Address:** 22 High Street, Brighton, BN2 1AA * **Provider NPI/GMC No.:** 9876543210 **5. Diagnosis/Reason for Visit (ICD-10 Code):** R05 - Cough **6. CPT/Service Code:** 99213 - Office or other outpatient visit for the evaluation and management of an established patient. **7. Total Billed Amount:** £75.00 **8. Amount Paid by Patient:** £0.00 **9. Amount Due:** £75.00 **10. Referring Physician (if applicable):** N/A **11. Patient Signature:** (Signature on file) **12. Date of Signature:** 1 November 2024 **13. Authorised Representative Signature (if applicable):** N/A