IBCF2P ;ALB/ARH - PRINT HCFA 1500 12-90 FORM ; 17-JUL-93
Source file <IBCF2P.m>
Name | Comments | DBIA/ICR reference |
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; print the form, IBFLD required
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LINE8 | ; insured's ID number
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LINE10 | ; patient name, DOB, sex; insured's name ("SAME" if patient)
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LINE12 | ; patient's address (street); pt. rel to ins.; insured's address
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LINE14 | ; patient addr city, state code, marital status; insured's city, state
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LINE16 | ; patient zip code, phone; patient employment status; insured's zip code, phone
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LINE18 | ; other insured's name; insured's policy group
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LINE20 | ; other insured's policy number; condition related to employment?; insured's date of birth and sex
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LINE22 | ; other insured's DOB, sex; patient auto accident & place; insured's employer
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LINE24 | ; other insured's employer; patient other accident; insured's insurance plan name
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LINE26 | ; other insured's plan name; is there another benefit plan *488* add box 10d
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LINE29 | ; patient's signature; insured's signature (use PL 99-272, SECTION 1729 TITLE 38)
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LINE32 | ; date of current illness; date of similar illness; dates unable to work *488*
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LINE34 | ; name of referring physician; ID# referring physician; hospitalization dates related to services
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LINE35 | ; "not for SC" note line 1
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LINE36 | ; "not for SC" note line 2; outside lab (now defaults to "no" in IBEHCFA)
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LINE37 | ; diagnosis code indicator *488*
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LINE38 | ; diagnosis codes 1-4 ; field 22 (MEDICAID) left blank *488*
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LINE39 | ; diagnosis codes 5-8 *488*
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LINE40 | ; diagnosis codes 9-12; field 23 (prior authorization #) *488*
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LINE44 | ;lines 44,46,48,50,52,54 all the same
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LINE56 | ||
LINE58 | ||
LINE69 | ||
LINE60 | ||
LINE61 | ||
END |
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