The objective of these exercises is to correctly complete workers compensation claims, applying what you have learned in the chapter. Each case has two sections. The first section contains information about the patient, the insurance coverage, and the current medical condition. The second section is an encounter form for Valley Associates, PC. If you are gaining experience by completing a paper CMS-1500 claim form, use the blank claim form supplied to you (from the back of the book or printed from the books Online Learning Center) and follow the billing notes on pages 255256 to fill in the form by hand. Alternatively, the Online Learning Center provides an electronic CMS-1500 form that can be used to fill in and print claims using Adobe Reader. See The Interactive Simulated CMS-1500 Form in Appendix B at the back of this text for further instructions. The following provider information, which is also available in the Medisoft database, should be used for Cases 12.1 and 12.2.

Provider Information Name Sarah Jamison, MD Address 1400 West Center Street Toledo, OH 43601-0213 Telephone 555-321-0987 Employer ID Number 07-2345678 NPI 5544882211 Assignment Accepts Signature On File (1-1-2016) Case 12.1 LO 12.112.4 From the Patient Information Form: Name Frank Puopolo Sex M Birth Date 05/17/1969 Marital Status M Address 404 Belmont Place Sandusky, OH 44870-8901 SSN 239-04-9372 Health Plan CarePlus Workers Compensation Insurance ID Number 2090462-37 Group Number OH111 Employer JV Trucking Condition Related to: Employment? Yes Auto Accident? No Other Accident? No Date of Current Illness, Injury, LMP 6/2/2016 Dates Patient Unable to Work 6/2/2016 Date of Hospitalization 6/2/2016

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