CMS-1500 CLM-02006

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CMS-1500 — CLM-02006

HEALTH INSURANCE CLAIM FORM — CMS-1500 (facsimile)
CLM-02006
1 Payer
Aetna
1a Insured ID
AET5540982
2 Patient name
Nguyen, Robert
3 DOB
Dec 21, 1962
5 Address
903 Maple Ave, Richardson TX
21 Diagnosis (ICD-10)
E11.9 G47.33
23 Prior Auth
—
24. Service lines
24A Date
Jun 20, 2026
B POS
12
D HCPCS
A4253
Mod
NU
E Dx
A
F Charges
$79.50
G Units
3
24A Date
Jun 20, 2026
B POS
12
D HCPCS
E0607
Mod
NU
E Dx
A
F Charges
$38.00
G Units
1
28 Total charge
$117.50
33 Billing provider
Lakeview Medical Supply · NPI 1980000000
Readable facsimile for demo. Production renders the official red-ink form / 837P EDI.