DISCHARGE ADVICE AND Claim number Oepartment ofVetcrans' Affairs HOSPITAL CLAIM The information sought on thifom1 is req uired for provider verification and claim processing. This information will used by Medicare Austrnlia to process the be Staple auachme.ns payment. bere br Please pri11t clearly BLOCK letters. Name and address of hospital Hospitalprovider number IOVA file number IPatient IIGiven IIDate Surname names of birth 1 ';I -I ISeparation I I I Code Principal l CD-10 Code Is this account 0 0 I interim or final? Interim Final I 0 I Is this a readmission within days? Yes NoD 7 I Admitted lor treabnent ol IDischarge I I Place to which dischiuged Name olIfeating OoctOJ I Your referenwlnvoitl!No. Admission dale date I 1 Patient Declaration Icertify that Ihave received the services described on this claim. Iam not entitled to claim third party or worker's compensation for these services. Patient Signature Icertify the patient OR is unable to sign Oftci er Signature Declaration Iclaim payment for the services specified above and certify that: to the best of my knowledge and belief all information given above is true •
Oepartment ofVetcrans' Affairs DISCHARGE ADVICE AND HOSPITAL CLAIM The information sought on thifom1 is req uired for provider verification and claim Claim number Staple auachme.ns bere processing. This information will be used by Medicare Austrnlia to process the payment. Please pri11t clearly br BLOCK letters. Name and address of hospital Hospitalprovider number IOVA file number IPatient Surname IIGiven names IIDate of birth 1 ';I -I I I Principal l CD-10 Code I Is this account interim or final? Interim 0 Final 0 I I Is this a readmission within 7 days? Yes 0 NoD I Admitted lor treabnent ol ISeparation Code I I Name olIfeating OoctOJ Admission dale IDischarge date I Place to which dischiuged I Your referenwlnvoitl!No. I 1 Patient Declaration Icertify that Ihave received the services described on this claim. Iam not entitled to claim third party or worker's compensation for these services. Patient Signature OR Icertify the patient is unable to sign Oftci er Signature Declaration Iclaim payment for the services specified above and certify that: • to the best of my knowledge and belief all information given above is true
Private_Hospital_Info_Pack.docx