General Instructions

The form is designed so that the Primary Payer's name and address (Item 3) is visible in a standard #10 window envelope. Please fold the form using the 'tick-marks' printed in the left and right margins.

In the upper-right of the form, a blank space is provided for the convenience of the payer or insurance company to allow the assignment of a claim or control number.

All Items in the form must be completed unless it is noted on the form or in the comprehensive instructions that completion is not required.

When a name and address field is required, the full name of an individual or business, address and zip code must be entered.

All dates must include the four-digit year.

If the number of procedures reported exceeds the number of lines available on one claim form, the remaining procedures must be listed on a separate, fully completed claim form.

Coordination Of Benefits

When a claim is being submitted to a secondary payer, complete the form in its entirety and attach the primary payer's Explanation of Benefits (EOB) showing the amount paid by the primary payer. You may indicate the amount the primary carrier paid in the "Remarks" field (Item # 35).