CV HCFA 1500 - ChiroVision Billing

Insurance Type & Program

Medicare Medicaid TRICARE CHAMPVA Group Health Plan FECA Other

1a Insured's ID Number

Patient Information

2 Patient's Name (Last, First, MI)

3 Patient's Birth Date

3 Sex

4 Insured's Name

5 Patient's Address

5 City

5 State

5 ZIP Code

5 Phone

6 Patient Relationship to Insured

11 Insured's Group Number

11c Insurance Plan Name

Condition Information

14 Date of Current Illness/Injury

15 Other Date

16 Dates Unable to Work From

16 Dates Unable to Work To

19 Additional Claim Information

Diagnosis Codes (ICD-10)

21A Diagnosis A

21B Diagnosis B

21C Diagnosis C

21D Diagnosis D

21E Diagnosis E

21F Diagnosis F

21G Diagnosis G

21H Diagnosis H

Common ICD-10 Codes (click to add)

M54.2 Neck M54.5 LBP M54.6 Thor M99.01 Cerv M99.02 Thor M99.03 Lumb M99.04 Sacr M99.05 Pelv M47.812 M50.20 M51.26

Services (Box 24)

Quick Date:

Date From	Date To	POS	CPT/HCPCS	Mod	Dx Ptr	$ Charges	Units
Total Charges:						$0.00

Billing Provider Information

33 Billing Provider Name & Address

Address

City

State

ZIP

Phone

33a NPI (Billing)

33b Other ID (Taxonomy/Legacy)

25 Federal Tax ID (EIN/SSN)

Tax ID Type

Rendering Provider (if different)

31 Rendering Provider Name

24J Rendering Provider NPI

32 Service Facility Location (if different from billing)

Authorization & Signatures

12 Patient's Signature

13 Insured's Signature

27 Accept Assignment

28 Total Charge

29 Amount Paid

30 Balance Due

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