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Get Insurance Claim Form Printable 1990-2024

and are made a part thereof.) SIGNED 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? (For govt. claims, see back) YES NO 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED (If other than home or office) DATE (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) 28. TOTAL CHARGE $ $ 30. BALANCE DUE $ 33. PHYSICIAN’S, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE & PHONE # PIN# PLEASE PRINT OR TYPE 29. AMOUNT PAID GRP# FORM HCFA-1500 (12-90), FORM RRB-1500, FORM OWCP-1500.

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