1
Q
Item 1
A
Type of health insurance coverage applicable to this claim
2
Q
Item 1a
A
Enter the patients insurance ID number
3
Q
Item 2
A
Patients last name, first name, and middle initial
4
Q
Item 3
A
Patients 8 digit birth date and sex
5
Q
Item 4
A
patient relationship to insured
6
Q
Item 5
A
Patients mailing address and phone number
7
Q
A
