CARRIER HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA MEDICARE MEDICAID Medicare TRICARE CHAMPUS Sponsor s SSN Medicaid GROUP HEALTH PLAN SSN or ID CHAMPVA Member ID 3. AUTO ACCIDENT PLACE State c. OTHER ACCIDENT c. INSURANCE PLAN NAME OR PROGRAM NAME NO YES d. IS THERE ANOTHER HEALTH BENEFIT PLAN 10d. RESERVED FOR LOCAL USE READ BACK OF FORM BEFORE COMPLETING SIGNING THIS FORM. 12. PATIENT S OR AUTHORIZED PERSON S SIGNATURE I authorize the release of any...
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