Block 12 OR If – PATIENT’S AUTHORIZED PERSON’S SIGNATURE – the provider already has an authorized signature on file for the patient, this section should on and include the billing date. read “Signature File” Block 13 OR If – INSURED’S AUTHORIZED PERSON’S SIGNATURE – the provider already has an authorized signature on file for the patient, the section should of and include the billing date. (No entry required read “Signature File” when billing for a FFS client or a client without third party insurance.) Block 14 DATE OF CURRENT ILLNES, OR INJURY OR PREGNANCY – Block 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS – (OTHER DATE) Block 16 DATES PATIENT UNABLE TO WORK IN CURRENT – OCCUPATION No entry required. – Block 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE – Note: Completion of 17-17b is only required for Lab and Other Diagnostic Services. Block 17 should be completed in cases where there is a referring physician. Completion is optional if a valid Medical Assistance individual practitioner identification number is entered in Block #17a. To complete, enter the full name of the ordering practitioner. Do not submit an invoice unless there is an order on file No entry required. that verifies the identity of the ordering practitioner. – Block 17a (gray shaded area) ID OF REFERRING PHYSICAIN Enter the – – ID Qualifier (Medicaid Provider Number) followed by the –1D provider’s Medicaid Provider Number. No entry required. – Block 17b Enter the NPI of the referring, ordering, or supervising provider listed – in Block 17. Block 18 HOSPITALIZATION DATES RELATED TO CURRENT – No entry required. SERVICES – Block 19 ADDITIONAL CLAIM INFORMATION – Check "no" Block 20 OUTSIDE LAB – – Block 21 DIAGNOSIS OR NATURE OF THE ILLNESS OR INJURY – –
Block 12 – PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE – If the provider already has an authorized signature on file for the patient, this section should read “Signature on File” and include the billing date. Block 13 – INSURED’S OR AUTHORIZED PERSON’S SIGNATURE – If the provider already has an authorized signature on file for the patient, the section should read “Signature of File” and include the billing date. (No entry required when billing for a FFS client or a client without third party insurance.) Block 14 – DATE OF CURRENT ILLNES, OR INJURY OR PREGNANCY Block 15 – IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS (OTHER DATE) Block 16 – DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION – No entry required. Block 17 – NAME OF REFERRING PHYSICIAN OR OTHER SOURCE Note: Completion of 17-17b is only required for Lab and Other Diagnostic Services. Block 17 should be completed in cases where there is a referring physician. Completion is optional if a valid Medical Assistance individual practitioner identification number is entered in Block #17a. To complete, enter the full name of the ordering practitioner. Do not submit an invoice unless there is an order on file that verifies the identity of the ordering practitioner. – No entry required. Block 17a (gray shaded area) – ID OF REFERRING PHYSICAIN – Enter the ID Qualifier –1D (Medicaid Provider Number) followed by the provider’s Medicaid Provider Number. – No entry required. Block 17b – Enter the NPI of the referring, ordering, or supervising provider listed in Block 17. Block 18 – HOSPITALIZATION DATES RELATED TO CURRENT SERVICES – No entry required. Block 19 – ADDITIONAL CLAIM INFORMATION Block 20 – OUTSIDE LAB – Check "no" Block 21 – DIAGNOSIS OR NATURE OF THE ILLNESS OR INJURY –