- 1). Check the appropriate type of health insurance that applies to the claim. Boxes appear at the top of the form above options such as "Medicare," "Medicaid," "Group Health Plan" and "Other."
- 2). Gather basic information about the patient and the insurance plan the patient carries. You need to know the patient's name, birth date and address. Additionally, you need to know information about the insurance plan such as the policy number and name of the plan. Write this information on the first half of the form (lines 1-13).
- 3). Review the services provided to the patient. Include information such as when the patient was admitted, who referred the patient (if applicable) and the diagnosis of the patient. Use ICD-9-CM codes to fill in diagnosis information. Write this information down on the second half of the form (lines 14-24).
- 4). Write down the total amount charged on line 28. Include any money paid by the patient on line 29. List the remaining balance on line 30.
- 5). Write the information about the health care facility and billing provider information on the final lines of the form (lines 31-33).
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