Question: 34 UNIT 4 Claims Submission In The Medical Office WORKERS COMPENSATION HEALTH INSURANCE CLAIM FORM PM RA TA Barton Poster 106 DF Construction 14BRO Day Avenge 1212 Hard Place Wood And HD XY Wood And H AD 12345-0000 (5569 4277098 12345-0000 (565) 276200 TENANCE MI * ERR LO ROOF W.PINTSON AUTOS Signature On The 1 Pc 451 FOOTER 027200 TEN TO 104 20XX HOGATE ...

34 UNIT 4 Claims Submission in the Medical Office WORKERS COMPENSATION HEALTH INSURANCE CLAIM FORM PM RA TA Barton Poster 106

this is fig. 14.10

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34 UNIT 4 Claims Submission in the Medical Office WORKERS COMPENSATION HEALTH INSURANCE CLAIM FORM PM RA TA Barton Poster 106 DF Construction 14BRO Day Avenge 1212 Hard Place Wood and HD XY Wood and H AD 12345-0000 (5569 4277098 12345-0000 (565) 276200 TENANCE MI * ERR LO ROOF W.PINTSON AUTOS Signature on the 1 pc 451 FOOTER 027200 TEN TO 104 20XX HOGATE 90 GO DOLORE CORNER M24419 COO PHOTO NOVO w SANOL TER 0227 XX 29055 15000 1 1261254 . XX1220XX X 100 150.00 HOLD College Cinc 4567 Broad Avenue Raymond Skelton MD Woodland XY 12345-0001 022820xx 3686021CC UOCO MAIS www FELEPHENOTY OM APPROVAL PEOR Fig. 14.10 An example of a completed CMS 1500 Health Insurance Cum form for workers compensation case

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