CPB Chapter 8 - claim forms

Question 1

Item 1

Answer 1

Type of health insurance coverage applicable to this claim

Question 2

Item 1a

Answer 2

Enter the patients insurance ID number

Question 3

Item 2

Answer 3

Patients last name, first name, and middle initial

Question 4

Item 3

Answer 4

Patients 8 digit birth date and sex

Question 5

Item 4

Answer 5

patient relationship to insured

Question 6

Item 5

Answer 6

Patients mailing address and phone number