Please help me fill up claim form accuratetely. Thanks

Case Study 2-1 GOODMEDICINE CLINIC 1 Provider Street . Anywhere, NY 12345 . (101) 111-2222 Case Study NPI: 3345678901 PROVIDER(S): HENRY C. CARDIAC, M.D. EIN: 22-1234567 NPI: 3456789012 PATIENT INFORMATION: INSURANCE INFORMATION: Name: Jose X. Raul Patient Number: 2-1 Address: 10 Main Street Place of Service: Office City: Anywhere Primary Insurance Plan: Bell Atlantic State: NY Primary Insurance Plan ID #: 222304040 Zip Code: 12345-1234 Group #: Telephone: (101) 111-5454 Primary Policyholder: SelfCity: Anywhere Primary Insurance Plan: Bell Atlantic State: NY Primary Insurance Plan ID #: 222304040 Zip Code: 12345-1234 Group #: Telephone: (101) 111-5454 Primary Policyholder: Self Gender: Male Policyholder Date of Birth: 01-01-1968 Date of Birth: 01-01-1968 Relationship to Patient: Occupation: Lineman Secondary Insurance Plan: Employer: Anywhere Telephone Co. Secondary Insurance Plan ID #: Spouse's Employer: Secondary Policyholder: Patient Status O Married Divorced X Single O Student Other DIAGNOSIS INFORMATION Diagnosis Code Diagnosis Code 1. 5.Patient Status Married U Divorced X Single Student Other DIAGNOSIS INFORMATION Diagnosis Code Diagnosis Code 1, 5. 2. 6. 3. 1. 4. 8. PROCEDURE INFORMATION Description of Procedure or Service Date Code Charge 1. Office consultation, level III 06-20-YYYY 100 .00 2. 3. 4. 5. SPECIAL NOTES: Referring Physician is I.M. Gooddoc, M. D. (NPI: 5678901234). Bell Atlantic, 100 Main St, Anvwhere US 12345GOODMEDICINE CLINIC 1 Provider Street . Anywhere, NY 12345 . (101) 111-2222 Patient Record PROVIDER: HENRY C. CARDIAC, M.D. RAUL, JOSE X. OFFICE CONSULTATION 06/20/YYYY S: Patient is an adult Mexican-American single male, referred by Dr. I.M. Gooddoc for consultation. He noted umbilical mass roughly five days ago, two days after the onset of pain in this region. There is no known etiology. He had been physically active, but within the past two months he has not engaged in normal physical activity. He has erratic bowel habits with defecation 2-3-4 days and has a history of having some bright red blood in the stool and on the toilet tissue. He has had no melanotic stool or narrowing of the stool. He denies episodic diarrhea. He has had bronchitis and sinus difficulties, particularly in the fall. He is a nonsmoker. He has no GU symptoms of prostatism. Health history reveals chronic nonspecific dermatitis of eyes, ears, hands and groin, and in fact, felt that bleeding in perianal region was secondary to this. He was a full-term delivery. History reveals maternal uncle had hernia similar to this. Medications include use of halogenated steroid for skin condition. HE HAS ALLERGIES IN THE FALL TO POLLEN. HE HAS SENSITIVITY TO PERCODAN OR PERCOCET, CAUSING NAUSEA, although he has taken Tylenol #3 without difficulty. He takes penicillin without difficulty. The family historynoncontributory. Details can be found in patient's history questionnaire. Supraclavicular fossae are free from adenopathy. Chest is clear to percussion and auscultation. No cutaneous icterus is present. Abdomen is soft and nontender, without masses or organomegaly. Penis is circumcised and normal. Testicles are scrotal and normal. No hernia is palpable in the groin. At the base of the umbilicus, there is suggestion of crepitus but no true hernia at this time. Rectal examination reveals normal tone. There is some induration of perianal tissues. The prostate is 3 x 4 cm and normal in architecture. Hemoccult testing of the formed stool is negative for blood. 1. Umbilical mass. Possible umbilical cyst, possible umbilical hernia. Rectal bleeding. 1. Schedule endoscopic evaluation of lower colon. 2. Schedule follow-up visit to evaluate progression of umbilical change. 3. Note dictated to Dr. Gooddoc. 949mg. 6mm, M35. Henry C. Cardiacr M.D. BELL ATLANTIC O 100 MAIN ST HEALTH INSURANCE CLAIM FORM ANYWHERE US 12345 -CARRIER- APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUOC) 02/12 PICA PICA 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP HEALTH PLAN OTHER 18. INSURED'S I.D. NUMBER (For Program in Item 1) (Medicare!) (Medicalde) (104/DoD4) Member 104) (104) 222304040 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) RAUL, JOSE, X 01 01 1968 M X F 5. PATIENT'S ADDRESS (NO., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (NO., Street) 10 MAIN STREET Sell Spouse Child other CITY STATE 8. RESERVED FOR NUCC USE CITY STATE ANYWHERE NY ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) 12345-1234 (101) 1115454 ( ) 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER NONE &. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH SEX PATIENT AND INSURED INFORMATION MM DD YY YES X| NO M FO b. RESERVED FOR NUCC USE b. AUTO ACCIDENT? PLACE (State) b. OTHER CLAIM ID (Designated by NUCC) YES X| NO C. RESERVED FOR NUCC USE c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME YES X| NO d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES (Designated by NUCC) d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES NO If yes, complete items 9, 9a, and 9d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below.HEAD BACK UP FUNM BEFORE COMPLETING & SIGNING INIS FUNM. 13, INSUMEU'S UM AUIMUMIZED PEHSUN'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED SIGNATURE ON F: DATE SIGNED SIGNATURE ON FI 14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP) 15. OTHER DATE QUAL MM | DD YY 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 06 20 ! YYYY QUAL 431 FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 178 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES J IM GOODDOC MD 17b NPI 5678901234 FROM TO 19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB? $ CHARGES YES NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) ICD Ind. 0 22. RESUBMISSION ORIGINAL REF. NO. A R19 . 05 B. K62 . 5 C. L D. E. F. G. 23. PRIOR AUTHORIZATION NUMBER H. 1. K. 24. A. DATE(S) OF SERVICE B. D. PROCEDURES, SERVICES, OR SUPPLIES E. H. From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS PSOT RENDERING MM DO YY MM DD YY SERVICE | EMG CPT/HCPCS MODIFIER POINTER S CHARGES QUAL PROVIDER ID. 06 20 YYY. 11 99243 A 100 00 1 NP 3456789012 NPI 3 PHYSICIAN OR SUPPLIER INFORMATION NPI 4 NPI 5 NPI 6 NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. Ravd for NUCC Use 221234567 X YES NO $ 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH INCLUDING DEGREES OR CREDENTIALS (i certify that the statements on the reverse apply to this bill and are made a part thereof.)