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CMS 1500 - (formerly L&I Health Ins Claim form)

DEPARTMENT OF LABOR AND INDUSTRIESCLAIMS SECTIONPO BOX 44269OLYMPIA WA 98504-4269

00987654302

Doe, Jane, A. ✘ DOE, JANE, A.

199 SOUTH FRANKLIN STREET 199 SOUTH FRANKLIN STREET

WASHINGTON PA

YD

WASHINGTON PA

16111 724 555-1212 16111 724 555-1212

10 15 09

UPMC FOR YOU

Z00 129

10 15 11 99383 EP

11 99173 EP

11 92552 EP

85 00 03

191919191 25647651

724 555-1212

DOCTOR'S OFFICE 66 PEDIATRIC STREET, WASHINGTON, PA 16111

Example of a completed claim for a 6-year EPSDT visit

UPMC for You encourages electronic claims submissions.

1a. INSURED’S ID NUMBER

#

25. FEDERAL TAX ID NUMBER SSN EIN

1111111111

15 10 15 15

10 15 15 10 15 15

10 15 15 10 15 15

Please do not staple in this area

CMS 1500 - (formerly L&I Health Ins Claim form)

DEPARTMENT OF LABOR AND INDUSTRIESCLAIMS SECTIONPO BOX 44269OLYMPIA WA 98504-4269

Example of a completed claim for a 2-3 month EPSDT visit

UPMC for You encourages electronic claims submissions.

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PATI

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AN

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00111111101

DOE, JOHN, H ✘ DOE, JOHN, H

1 FRONT STREET 1 FRONT STREET

PITTSBURGH PA PITTSBURGH PA

16111 724 555-1212 16111 724 555-1212

01 15

UPMC FOR YOU

Z00 129

10 15 11 99381 EP 85 00 03

191919191 25647651

724 555-1212

123 Pediatrics 999 Johnston Street, Pittsburgh, PA 15444

9876543219

1a. INSURED’S ID NUMBER

#

25. FEDERAL TAX ID NUMBER SSN EIN

08

15 10 15 15