Cape Medical Billing: Providing Expert Medical Billing Solutions

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Section 1: Patient Information
Patient Account Number:   
Patient Name:  Last First Middle Initial Suffix:
Patient's Social Security Number:
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-
*Patient's Date of Birth:
/
/
(mm/dd/yyyy)
 
Section 2: Patient Demographic Information
Please use this section for changes and corrections to your demographic information to ensure that your insurance claims are processed in timely fashion.
Patient Address:  (House number and street)
Apartment Number:  (if applicable)  City:  State:  Postal Code:
Phone Number 1:
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-
Phone Number 2:
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Section 3: Insurer/Guarantor Information
Are you the parent, guardian or legally responsible person for the patient?
 
Section 4: Primary Insurance Information
Please fill in all information
Insurance Company Name:
Address: (Address to submit claims to)
City:  State: Postal Code:
Phone Number:
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-
Fax Number:
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Policy Number: Group Number: (if applicable)
Subscriber's Last Name: First Name: Middle Initial:
Subscriber's Date of Birth:
/
/
(mm/dd/yyyy)
Relationship to Patient: Explain, if Other:
Effective Dates of Insurance:
/
/
To
/
/
(mm/dd/yyyy)
 
Section 5: Motor Vehicle Accident / Worker's Compensation Claim
Please use this section to supply information if this is due to an auto accident or worker's compensation claim.
Type of Claim: Is your Claim
Insurance Company Name:
Address:   City:  State: Postal Code:
Claim Number: (This is the number given by your adjuster, not the policy number)
Date of Accident:
/
/
(mm/dd/yyyy)
Adjuster's Name:
Adjuster's Phone Number:
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Adjuster's Fax Number:
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-
 
Section 6: Secondary Insurance Information
Please fill in all information
Insurance Company Name:
Address: (Address to submit claims to)
City:  State: Postal Code:
Phone Number:
-
-
Fax Number:
-
-
Policy Number: Group Number: (if applicable)
Subscriber's Last Name: First Name: Middle Initial:
Subscriber's Date of Birth:
/
/
(mm/dd/yyyy)
Relationship to Patient: Explain, if Other:
Effective Dates of Insurance:
/
/
To
/
/
(mm/dd/yyyy)
 
Section 7: Tertiary Insurance Information
Please fill in all information
Insurance Company Name:
Address: (Address to submit claims to)
City:  State: Postal Code:
Phone Number:
-
-
Fax Number:
-
-
Policy Number: Group Number: (if applicable)
Subscriber's Last Name: First Name: Middle Initial:
Subscriber's Date of Birth:
/
/
(mm/dd/yyyy)
Relationship to Patient: Explain, if Other:
Effective Dates of Insurance:
/
/
To
/
/
(mm/dd/yyyy)
 

Section 8: Additional Comments
Please use this area to add any information that you feel would be important for us to make sure that your claim is handled in a expeditious manner.