Health care coverage being billed - Section 1, Patient’s name - Section 2, Insured’s name - Section 4, Patient’s condition is result of employment - Section 10a, Indicate there is another health plan - Section 11d, Diagnosis code - Section 21, Insured’s policy group or FECA number - Section 11, Procedure code - Section 24d, Name of referring provider - Section 17, Federal tax ID number - Section 25,

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