CMS-1500 CLM-02008
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CMS-1500 — CLM-02008
HEALTH INSURANCE CLAIM FORM — CMS-1500 (facsimile)
CLM-02008
1 Payer
Medicare (Railroad/Part B)1a Insured ID
4M81-RR-5522 Patient name
Ellis, Margaret3 DOB
Sep 3, 19445 Address
17 Lakeview Terrace, Dallas TX21 Diagnosis (ICD-10)
J96.11 J44.923 Prior Auth
—24. Service lines
28 Total charge
$0.0033 Billing provider
Lakeview Medical Supply · NPI 1980000000Readable facsimile for demo. Production renders the official red-ink form / 837P EDI.