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HCR 220 Week 8 CheckPoint_ Complete a CMS-1500 Claim Form
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CheckPoint: Complete a CMS-1500 Claim Form Resource: Appendix C Due Date: Day 5 [Individual forum] Use the following data to complete the CMS-1500 claim form worksheet located in Appendix C. If you believe information provided in the following list is insufficient to adequately fill a required field with data (for example, to supply a specific diagnosis code), indicate this by typing “N/A” in the box. If no patient information whatsoever has been given for a specific field, leave it blank. Name: Katherine Doe Insurer: TRICARE Policy Number: 123456 ID number: 999000666 DOB: 01/01/1950 Gender: Female Insured: James Doe, spouse Address: 1111 Noname Court Nowhere, NY 22222 Marital Status: Married Patient’s Employer: Homemaker Spouse’s Employer: U.S. Army Nature of Condition: Routine exam Patient SignatureHCR 220 Claims Preparation I: Clean Bills of HealthCourse Syllabus Page 18 Post the completed CMS-1500 form as an attachment.
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