If yes
CA
RR
IER
PATI
ENT
AN
D IN
SUR
ED IN
FOR
MA
TIO
NPH
YSIC
IAN
OR
SU
PPLI
ER IN
FOR
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N
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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
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.
If yes
CA
RR
IER
PATI
ENT
AN
D IN
SUR
ED IN
FOR
MA
TIO
NPH
YSIC
IAN
OR
SU
PPLI
ER IN
FOR
MA
TIO
N
NPI NPI
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
