Ugonna Mbaegbu

CARRIER HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 PICA PICA (Medicare #) MEDICAID TRICARE CHAMPVA (Medicaid #) (ID#DOD#) (Member ID#) 2. PATIENT’S NAME (Last Name, First Name, Middle Initial) GROUP HEALTH PLAN (ID#) 3. PATIENT’S BIRTH DATE MM DD YY Mandelberg, Arielle 09 5. PATIENT’S ADDRESS (No., Street) OTHER 1a. INSURED’S I.D. NUMBER FECA BLK LUNG (ID#) (ID#) 4. INSURED’S NAME (Last Name, First Name, Middle Initial) SEX 09 1990 M 123 Example Street Self STATE Child Spouse Mandelberg, Arielle F 7. INSURED’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED CITY (For Program in Item 1) 123 Example Street Other CITY 8. RESERVED FOR NUCC USE STATE CA ZIP CODE CA TELEPHONE (Include Area Code) ( 55555 ZIP CODE ) TELEPHONE (Include Area Code) ( 55555 9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: ) 11. INSURED’S POLICY GROUP OR FECA NUMBER 890876 a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) b. RESERVED FOR NUCC USE b. AUTO ACCIDENT? YES NO c. RESERVED FOR NUCC USE F b. OTHER CLAIM ID (Designated by NUCC) c. INSURANCE PLAN NAME OR PROGRAM NAME c. OTHER ACCIDENT? YES d. INSURANCE PLAN NAME OR PROGRAM NAME M - PLACE (State) NO YES SEX a. INSURED’S DATE OF BIRTH MM DD YY NO d. IS THERE ANOTHER HEALTH BENEFIT PLAN? 10d. CLAIM CODES (Designated by NUCC) YES READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary NO PATIENT AND INSURED INFORMATION 1. MEDICARE If yes, complete items 9, 9a and 9d. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize services described below. below. Signature on File DATE 14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP): MM DD YY QUAL. 09 09 25 431 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 15. OTHER DATE QUAL. 09/23/2025 MM DD YY 09 10 25 454 17a. 17b. NPI 20. OUTSIDE LAB? 19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) Referral# REF23456 YES 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) A. H40.052 E. I. 24. A. MM 1 2 N- N- ICD Ind. B. C. D. F. G. H. K. L. J. DATE(S) OF SERVICE From To DD YY MM DD YY Signature on File SIGNED 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD YY FROM TO 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO B. C. PLACE OF SERVICE EMG D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER ML- ME- $ CHARGES NO 22. RESUBMISSION CODE 0 ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER - E. DIAGNOSIS POINTER G. F. $ CHARGES H. DAYS OR UNITS I. EPSDT ID. Family Plan QUAL. a 150 00 1 NPI a 50 00 1 NPI 3 J. RENDERING PROVIDER ID. # NPI 4 NPI 5 NPI 6 NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. - 27. ACCEPT ASSIGNMENT? ( For govt. claims, see back ) YES 28. TOTAL CHARGE $ NO 200 00 29. AMOUNT PAID - 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) 32. SERVICE FACILITY LOCATION INFORMATION Primary Office Zenith Mental Wellness Centre U. MBAEGBU , , 09/23/2025 SIGNED DATE a. NUCC Instruction Manual available at: www.nucc.org NPI b. PLEASE PRINT OR TYPE 33. BILLING PROVIDER INFO & PH # a. NPI 30. Rsvd for NUCC Use $ b. APPROVED OMB- FORM CMS 1500 (02-12) PHYSICIAN OR SUPPLIER INFORMATION SIGNED