Block 1-13: – Patient and Insured Information.

Block 1. Show the type of health insurance coverage applicable to this claim by checking the appropriate box, e.g., if a Medicare claim is being filed check the Medicare box.

Block la. Enter the patient’s Medicare Health Insurance Claim Number (HICN) whether Medicare is the primary or secondary payer.

Block 2. Enter the patient’s last name, first name, and middle initial, if any, as shown on the patient’s Medicare card.

Block 3. Enter the patient’s birth date and sex.

Block 4. If there is insurance primary to Medicare, either through the patient’s or spouse’s employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word SAME. If Medicare is primary, leave blank.

Block 5. Enter the patient’s mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and phone number.

Block 6. Check the appropriate box for patient’s relationship to insured when Block 4 is completed.

Block 7. Enter the insurer’s address and telephone number. When the address is the same as the patient’s, enter the word “SAME.”