APPROVED OMBB FORM CMS () OMB No. Expires: 06/30/ Instructions for Completing OWCP Health Insurance Claim Form For Medical Services Provided Under the FEDERAL EMPLOYEES' COMPENSATION ACT (FECA), the BLACK LUNG BENEFITS ACT (BLBA), and the ENERGY EMPLOYEES OCCUPATIONAL ILLNESS. · To print CMS claim form, you will need a copy of Adobe Acrobat Reader, which you can download for free right here. Download the form below and open the PDF using the Acrobat Reader software, then simply enter your information into the form fields and print onto your pre-printed CMS claim forms using an inkjet or laser printer. BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BY APPLICABLE PROGRAMS. NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may CMS Template Author.
BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BY APPLICABLE PROGRAMS. NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may CMS Template Author. Instructions on how to fill out the CMS Form o Workers' Compensation (Type 15); o Black Lung (Type 41); and o Veterans Benefits (Type 42). NOTE: For a paper claim to be considered for Medicare secondary payer benefits, a policy or group number must be entered in this bltadwin.ru addition, a copy of the primary payer's explanation of benefits (EOB) notice must be. The following tips will help you fill out CMS successfully and accurately: Always use Pica or Arial fonts to fill out these forms. The font size is between 10 and Fill the form with capital letters and always use black ink or black fonts. Do not use italics or broken characters, dot matrix fonts, stylized fonts, or red ink when filling.
FORM SUBMISSION DFELHWC-FECA: Send all forms for FECA to OWCP/DFELHWC-FECA, PO Box , London, KY , () DEEOIC: Send all forms for DEEOIC to Energy Employees Occupational Illness Compensation Programs, PO Box , London, KY APPROVED OMB FORM () 1a. INSURED’S I.D. NUMBER (For Program in Item 1) 4. INSURED’S NAME (Last Name, First Name, Middle Initial) 7. INSURED’S ADDRESS (No., Street) CITY STATE ZIP CODE TELEPHONE (Include Area Code) INSURED’S POLICY GROUP OR FECA NUMBER a. INSURED’S DATE OF BIRTH b. To print CMS claim form, you will need a copy of Adobe Acrobat Reader, which you can download for free right here. Download the form below and open the PDF using the Acrobat Reader software, then simply enter your information into the form fields and print onto your pre-printed CMS claim forms using an inkjet or laser printer.
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