Three New Companies That Sell The Cms 1500 Claim Form
{"Image DocumentName": "CMS-1500Using the basic guidelines, complete the blank CMS form for a commercial carrier using the information provided here:", "Image ImageDescription": "Patient Information: Mari Lou Walin DOB: 4/12/ Main Street SSN: Anytown, US Employer: State of US Dpouse: John J. Insurance Information: Carrier: Aetna Policy #: Insured: Mari Lou Group #: US8901. Authorization to release information and assignment of benefits to provider, both on file. Provider Information: David A. Dodoc, M.D. EIN: Medical Care East Provider NPI: Welbeing Way Facility NPI Alltowns, US Appointment Information (Use today\u2019s date) Diagnoses. New Patient Level III   Chest Pain ECG   Family Hx Heart Disease V17.4. Venipuncture (Lipid Panel)   Hypertension", "Image XResolution": "14", "Image YResolution": "14", "Image ResolutionUnit": "Pixels/Inch", "Image Software": "SlidePlayer", "Image YCbCrPositioning": "Centered"}