Healthcare Insurance Claim
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]
