AGENCY: Department of Health and Human Services. Office of Children with Special Healthcare Needs

SERIES: 7810
TITLE: Health insurance claim forms
DATES: 1982-

DESCRIPTION: These are bills submitted by this bureau for payment for services rendered that are covered by medicaid. This record is used as a control document to ensure that payment is received. It includes patient's name, address, telephone number, date of birth, and sex; name and address of the insured party, the insured's identification number and group policy number, and the relationship between the patient and the insured; the name, address, policy number, and policy holder of other health insurance coverage; whether the patient's condition was caused by an accident; the signatures and dates of signature of the patient and the person who is to authorize payment; the date of the illness or injury; the date the patient first saw the physician; if the patient is disabled, the dates of partial or total disability; if the patient has previously had these symptoms; the name of the referring physician; the dates the patient admitted to and discharged from the hospital; the name and address of the medical facility where the service was rendered; whether laboratory work was performed and the amount of the charges; the diagnosis; the dates and place of medical service; the procedures code; a description of the services and supplies furnished; the amount of the charges; the name, address, and identification number of the physician or supplier; the provider type; the physician or supplier's social security number, employer identification number, and signature; the patient's account number; the total charge; the amount paid by the patient; and the balance due.


Retain until final action




These records are in Archives' permanent custody.

APPROVED: 08/1986


Paper: Retain in Office until payment is received and then destroy.


Administrative Fiscal

This record is used only to ensure that the bureau actually receives payment of the bills. As a record of the billing is kept in the Ledger Cards and in the Division of Health Care Finance, this copy of the form need not be kept after payment has been received.