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Appendix C 1. MEDICARE (Medicare #) MEDICAID (Medicaid #) TRICARE CHAMPUS (Sponsors SSN) CHAMPVA (Member ID #) GROUP health PLAN (SSN or ID) FECA BLK LUNG (SSN) OTHER (ID) rouse M 1a. INSUREDS I.D. # (For broadcast in Item 1) 999000666 4. INSUREDS NAME (Last Name, first gear Name, MI) F 2. long-sufferingS NAME (Last Name, First Name, MI) Doe, Katherine 5. PATIENTS ADDRESS ( #, Street) 3. PATIENTS BIRTH fancy MM DD YY 01 01 1950 Child Other Doe, James 7. INSUREDS ADDRESS ( #, Street) 6. PATIENT kindred TO INSURED Self Spouse 8. PATIENT STATUS integrity Employed CITY STATE PH O EN CITY 1111 Noname Court Nowhere ZIP CODE 1111 Noname Court NY TELEPHONE (Include Area Code) marry Full-Time Student Other Nowhere ZIP CODE TELEPHONE (Include Area Code) 22222 ( ) N/A parttime Student 22222 ( 9. OTHER INSUREDS NAME (Last Name, First Name, MI) 10. IS PATIENTS CONDITION RELATED TO: 11. INSUREDS polity GROUP OR FECA # 123456 MM a. OTHER INSUREDS polity OR GROUP # a. EMPLOYMENT? (Current of Previous) YES NO a. INSUREDS DATE OF BIRTH DD YY M b. INSUREDS DATE OF BIRTH MM DD YY M c. EMPLOYERS NAME OR instill NAME SEX F b. AUTO ACCIDENT? YES c. OTHER ACCIDENT? YES 10d.

LOCAL drug abuse NO NO PLACE (State) b. EMPLOYERS NAME OR SCHOOL NAME U.S Army Tricare YES c. INSURANCE PLAN NAME OR chopine NAME None d. INSURANCE PLAN NAME OR PROGRAM NAME d. HEALTH BENEFIT PLAN? NO If yes, return to and complete item 9 a-d. 14. DATE OF CURRENT: MM DD YY ILLNESS (First symptom) OR impairment (Accident) OR PREGNANCY (LMP) 15. IF PATIENT HAS HAD SAME OR corresponding ILLNESS. GIVE FIRST DATE MM DD YY O SIGNED SIGNATURE ON FILE DATE F READ BACK OF FORM BEFORE COMPLETING & sign THIS FORM. 12. PATIENTS OR countenance PERSONS SIGNATURE 13. INSUREDS OR AUTHORIZED PERSONS SIGNATURE . SIGNED FROM 16. DATES PATIENT UNABLE TO WORK IN... If you expect to get a full essay, order it on our website: Orderessay

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