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"     REQUEST FOR MEDICARE PAYMENT
MEDICAL INSURANCE-BENEFITS—SOCIAL SECURITY ACT.
SLUE SHIELD M£DM-4L'|g6r(See Instructions on Back—Type or Print Information)
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$8
.JFprw, Approved
Budget Bureau No.
72-RO730
MAR
California Blue Shield
P.O. Box 7968 Rincon Annex
San Francisco, California 94119
(Copy from your
1  4   19 6R HEALTH
:  INSURANCE
CARD X
(See example Ifr
on back)
Name of patient
EI
□
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Health insurance claim number
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QHVIale    D Female
Patient's street addre^|ipfe
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City, State, ZIP code ,
Telephone Number
Describe the illgessat.!* injury for which you received treatment (Always fill in ttfip item if your doctor does not
complete Partp"bef6w)
__?~ ^
/
Was your illness or
injury connected with
your employment?
□ Yes    □ No
If you have other health insurance or if your State medical assistance agency will pay part of your medical expenses and you want
information about this claim released to the insurance company or State agency upon its request, give the following information.
Insuring organization or State agency name and address
Policy No.
Medi-cril Idc/ntification No.
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I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or
carriers any information needed for this or a related Medicare claim, I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment below.
Signature of patient (See instructions on reverse where patient is unable to sign)
SIGN A
HERET
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>   /
*x!S
Date signed
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7 a.
Date of
<|ach
service
*     B.
Place of
service
('■See Codes
below)
Code surgical or medical procedures and
other services or supplies furnished
for each date given
D.
Nature of illness or
injury requiring services
or supplies
• Code
. • \
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<A
^    *    L/')
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8 Name and address
State, ZIP code)
physician or supplier (Numbeiwand street, city,    Telephone No.
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o
ass v a
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Physician or
supplier code
12 Assignment of patient's Bill
^\P I accept assignment
^   x	
D I do not accept assignment
13 Show name and address of facility where1
formed (If other than home oi|§5g£e visits)
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14 Signature of physician or supplier (A physician's signature certifies that physician's
*    services were personally rendered by him or under his personal direction)
DMD       D DO
Other degree —
□
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O—Doctors Office
IL—Independent Laboratory
H—Patient's Home (If portable X-ray services, identify the supplier)
IH—Inpatient Hospital
ECF—Extended Care Facility
OH—Outpatient Hospital
OL—Other Locations
NH—Nursing HoiyY//
form SSA-1490D (CA) .u-68)
Department of Health, Education, and Welfare
Social Security Administration