Medical Insurance Claim Form

Medical Insurance Claim Form PDF Patient Information: Patient Name: [Sarah Jenkins] Date of Birth: [15/03/1988] Address: [12 Meadow Lane, Anytown, AB1 2CD] Phone Number: [07700 900123] Insurance Provider: [HealthSure UK] Policy Number: [HSU87654321] Provider Information: Provider Name: [Occupational Therapy Solutions] Clinician Name: [Dr. Eleanor Vance] NPI/Provider ID: [OT54321098] Address: [7 Oak Street Clinic, Anytown, AB2 3DE] Phone Number: [01234 567890] Diagnosis and Treatment: Primary Diagnosis (ICD-10 Code): [G90.50 - Complex regional pain syndrome, unspecified] Secondary Diagnosis (ICD-10 Code): [M79.604 - Pain in right hand] Date of Service: [01/11/2024] Type of Service: [Occupational Therapy Assessment and Intervention] Description of Services: [Initial assessment of right hand function and pain, development of a home exercise program, and provision of adaptive equipment recommendations for daily living activities. Focus on improving grip strength, fine motor skills, and pain management strategies.] CPT/Service Code(s): [97165 - Occupational therapy evaluation, low complexity; 97530 - Therapeutic activities] Units/Duration: [1 unit (60 minutes) for evaluation; 2 units (30 minutes each) for therapeutic activities] Total Billed Amount: [£180.00] Referral Information: Referring Physician (if applicable): [Dr. Michael Lee] Referring Physician NPI/ID: [GP12345678] Patient Signature: [Sarah Jenkins] Date: [01/11/2024] Provider Signature: [Dr. Eleanor Vance] Date: [01/11/2024]