Healthcare Insurance Claim Template
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Healthcare Insurance Claim
I. Patient Information
Name: | [Your Name] |
Address: | 1234 Elm Street, Springfield, IL 62704 |
Contact Number: | (555) 123-4567 |
Insurance ID: | ABCD1234567890 |
II. Provider Information
Name: | Dr. Jane Smith |
Specialty: | Internal Medicine |
Practice Name: | Springfield Health Clinic |
Address: | 5678 Oak Street, Springfield, IL 62704 |
Contact Number: | (555) 987-6543 |
NPI Number: | 1234567890 |
III. Service Information
Date of Service | Service Provided | Procedure Code | Amount Charged |
|---|---|---|---|
January 10, 2055 | Office Visit | 99213 | $150.00 |
January 10, 2055 | Blood Test | 80050 | $75.00 |
IV. Diagnosis Information
Primary Diagnosis: Essential Hypertension
ICD-10 Code: I10
V. Billing Information
Total Amount Billed: $225.00
Co-Payment Collected: $25.00
Amount Due from Insurance: $200.00
VI. Insurance Information
Insurance Company Name: | Elite Health Insurance |
Policy Number: | H12345XYZ |
Group Number: | 7890 |
Insurance Company Address: | 9012 Maple Avenue, Springfield, IL 62701 |
Customer Service Contact: | (555) 321-9876 |
VII. Authorization and Signature
This claim is submitted for reimbursement of medical services rendered as detailed in the sections above.
[Your Name]
[Date Signed]
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