Add CMS Claim

Hidden

Submitted User Email

Hidden

Current Date

Insurance Company Information

Insurance Company Choices

Hidden

Insurance Company Name

Hidden

Address

Hidden

City

Hidden

State

Hidden

Zip

Incident Details

Incident Number(Required)

Date of Loss(Required)

Claim or Policy Type

Insured ID Number

This field is to be filled in with the Insured ID Number (Policy #, Claim #, etc.)

Insured Information

Insured Name

First Last

Insured Address

Street Address City State ZIP Code

Insured Date of Birth

Insured Phone Number

Patient Relationship Status

Relationship to Insured

Self

Spouse

Child

Other

Address Same as Insured?

Yes

Patient Information

Patient Name

First Last

Patient Address

Street Address City State ZIP Code

Hidden

Patient Address - Same as Insured

Street Address City State ZIP Code

Patient Date of Birth

Patient Phone Number

Hidden

PDF Patient Information

Hidden

PDF Patient Name

First Last

Hidden

PDF Patient Address

Street Address City State ZIP Code

Hidden

PDF Patient Date of Birth

Hidden

PDF Patient Phone Number

Medical Details

CMS Product List

CPT Code Choices	Qty Used	Product Charge	Date Of Loss	CPT Code	CPT Description	CPT Price	Place of Service Code	EMG Code	Diagnosis Pointer	Actions

There are no Codes.

CMS Code

V49.9XXA code extrication only
V89.2XXA CMS code only

Total Charge

Price: $0.00

Incident Location

Street Address City State ZIP Code