{"id":5835,"date":"2019-08-27T00:17:14","date_gmt":"2019-08-27T00:17:14","guid":{"rendered":"http:\/\/mportal.jipanetwork.com\/?page_id=5835"},"modified":"2019-08-30T19:22:32","modified_gmt":"2019-08-30T19:22:32","slug":"medical-claim-forms","status":"publish","type":"page","link":"https:\/\/mportal.jipanetwork.com\/?page_id=5835","title":{"rendered":"Medical Claim Forms"},"content":{"rendered":"\n<style>\nstrong {font-size:18px}\n.labels {text-align:left;font-weight:bold;font-size:smaller;vertical-align:bottom;white-space: nowrap;border-bottom:none;padding-bottom:0px}\n.data {text-align:left;vertical-align:top;}\ntr.labels {height:50%}\n<\/style>\n<script>\nfunction adjustRelation() {\n\tvar spouse = document.getElementById('spouse');\n\tvar child  = document.getElementById('child');\n\tvar other  = document.getElementById('other');\n\n\tif (spouse.checked) {\n\t\tspouse.value='S';\n\t\tchild.value='';\n\t\tother.value='';\n\t}\n\tif (child.checked) {\n\t\tspouse.value='';\n\t\tchild.value='C';\n\t\tother.value='';\n\t}\n\tif (other.checked) {\n\t\tspouse.value='';\n\t\tchild.value='';\n\t\tother.value='O';\n\t}\n}\n<\/script>\n<table><tbody><tr style=\"vertical-align:top;\"><td colspan=\"3\" style=\"text-align:left;\"><img class=\"wp-image-5\" style=\"width: 200px;\" src=\"https:\/\/mportal.jipanetwork.com\/wp-content\/uploads\/2019\/08\/JIPA-Full-Logo_RGB_web2.png\" alt=\"\"><br><strong>PROVIDER SUPPORT<br>1.855.275.1270, OPTION 4<\/strong><\/td><td style=\"text-align:right;\" colspan=\"2\"><strong>MEDICAL CLAIM FORM<\/strong><br>Forward Form and Bills to:<br>JIPA Network\/Claims<br>PO BOX 2788<br>Kennesaw, GA 30156-9114 USA<br>fax: 1.770.810.3789<br>email: claims@jipanetwork.com<\/td><\/tr><\/tbody>\n<tr class=\"labels data\">\n<td colspan=\"3\"><label>Group\/Plan Name or Number:<\/label>\n<input name=\"plan\" id=\"plan\" type=\"text\" size=\"10\" maxlength=\"15\">\n<\/td>\n<td colspan=\"2\"><label>Insured&#8217;s ID Number:<\/label>\n<input name=\"idnumber\" id=\"idnumber\" size=\"15\" maxlength=\"15\">\n<\/td>\n<tr style=\"background-color:lightgrey\"><td colspan=\"5\"><label><strong>PART 1: MUST BE COMPLETED BY INSURER<strong><\/label><\/td>\n<\/tr>\n<tr class=\"labels\">\n<td class=\"labels\"><label>Insured&#8217;s Last Name:<\/label><\/td>\n<td class=\"labels\"><label>First:<\/label><\/td>\n<td class=\"labels\"><label>Middle:<\/label><\/td>\n<td class=\"labels\"><label>Patient&#8217;s Birth Date:<\/label><\/td>\n<td class=\"labels\"><label>Patient&#8217;s ID Number:<\/label><td>\n<\/tr>\n<tr class=\"data\">\n<td><input id=\"inslname\" name=\"inslname\" maxlength=\"25\" size=\"25\" required><\/td>\n<td><input id=\"insfname\" name=\"insfname\" maxlength=\"15\" size=\"15\" required><\/td>\n<td><input id=\"insmiddle\" name=\"insmiddle\" maxlength=\"1\" size=\"1\"><\/td>\n<td><input id=\"patDOB\" name=\"patDOB\" maxlength=\"15\" size=\"15\" placeholder=\"MM\/DD\/YYYY\" required><\/td>\n<td><input id=\"patIDNO\" name=\"patIDNO\" maxlength=\"15\" size=\"11\" required><\/td>\n<\/tr>\n<tr class=\"labels\">\n<td class=\"labels\"><label>Patient&#8217;s Last Name:<\/label><\/td>\n<td class=\"labels\"><label>First:<\/label><\/td>\n<td class=\"labels\"><label>Middle:<\/label><\/td>\n<td class=\"labels\"><label>Patient&#8217;s Gender:<\/label><\/td>\n<td class=\"labels\"><label>Patient&#8217;s Relationship to Insured:<\/label><\/td>\n<\/tr>\n<tr class=\"data\">\n<td><input id=\"patlname\" name=\"patlname\" maxlength=\"25\" size=\"25\" required><\/td>\n<td><input id=\"patfname\" name=\"patfname\" maxlength=\"15\" size=\"15\" required><\/td>\n<td><input id=\"patmiddle\" name=\"patmiddle\" maxlength=\"1\" size=\"1\"><\/td>\n<td>\n<input type=\"radio\" id=\"patfemale\" name=\"gender\" value=\"\" onchange=\"if (this.checked) {this.value='F';patmale.value=''}\" required\/>&nbsp;<label for=\"patfemale\">Female&nbsp;<\/label>&nbsp;\n<input type=\"radio\" id=\"patmale\" name=\"gender\" value=\"\" onchange=\"if (this.checked) {this.value='M';patfemale.value=''}\"\/>&nbsp;<label for=\"patmale\">Male<\/label><\/td>\n\n<td class=\"data\" id=\"relationCell\">\n<input type=\"radio\" id=\"spouse\" name=\"relation\" required onchange=\"adjustRelation()\"><label>Spouse<\/label>&nbsp;&nbsp;\n<input type=\"radio\" id=\"child\" name=\"relation\" onchange=\"adjustRelation()\"><label>Child<\/label>&nbsp;&nbsp;\n<input type=\"radio\" id=\"other\" name=\"relation\" onchange=\"adjustRelation()\"><label>Other<\/label>\n      <\/td>\n<\/tr>\n<tr class=\"labels\">\n<td class=\"labels\" colspan=\"3\"><label>Street Address:<\/label><\/td>\n<td class=\"labels\"><label>Home Phone #:<\/label><\/td>\n<td class=\"labels\"><label>Cell Phone #:<\/label><\/td>\n<\/tr>\n<tr class=\"data\">\n<td colspan=\"3\" style=\"border-bottom:none\"><input id=\"address1\" name=\"address1\" maxlength=\"100\" size=\"100\" required><\/td>\n<td><input id=\"homeph\" name=\"homeph\" size=\"15\" maxlength=\"15\"><\/td>\n<td><input id=\"cellph\" name=\"cellph\" size=\"15\" maxlength=\"15\"><\/td>\n<\/tr>\n\n<tr class=\"labels\">\n<td class=\"labels\" style=\"border-right:none\"><label>City\/Town:<\/label><\/td>\n<td class=\"labels\" style=\"border-right:none\"><label>Parish\/State:<\/label><\/td>\n<td class=\"labels\"><label>Zip\/Postal Code:<\/label><\/td>\n<td class=\"labels\" colspan=\"2\"><label>Email:<\/label><\/td>\n<\/tr>\n<tr class=\"data\">\n<td style=\"border-right:none\"><input id=\"city\" name=\"city\" maxlength=\"25\" size=\"50\"><\/td>\n<td style=\"border-right:none\"><input id=\"state\" name=\"state\" maxlength=\"25\" size=15\"><\/td>\n<td><input id=\"zip\" name=\"zip\" maxlength=\"15\" size=\"10\"><\/td>\n<td colspan=\"2\">\n<input id=\"email\" name=\"email\" size=\"30\" maxlength=\"40\"><\/td>\n<\/tr>\n<tr class=\"labels\">\n<td colspan=\"2\" class=\"labels\"><label>Date the patient&#8217;s accident or sickness began:<\/label><\/td>\n<td class=\"labels\"><label>Did accident happened at work?<\/label><\/td>\n<td class=\"labels\"><label>Has claim been filed by workers?<\/label<\/td>\n<td class=\"labels\"><label>Is the patient a full time student?<\/label><\/td>\n<\/tr>\n<tr class=\"data\">\n<td class=\"data\" colspan=\"2\">\n<input id=\"sicknessDt\" name=\"sicknessDt\" maxlength=\"15\" size=\"15\" placeholder=\"MM\/DD\/YYYY\" required><\/td>\n<td><input type=\"radio\" name=\"workaccident\" id=\"workaccidentyes\"><label for=\"workaccidentyes\">Yes<\/label>\n<input type=\"radio\" name=\"workaccident\" id=\"workaccidentNo\"><label for=\"workaccidentno\">No<\/label><\/td>\n<td><input type=\"radio\" name=\"workcompfiled\" id=\"workcompfiledyes\"><label for=\"workcompfiledyes\">Yes<\/label>\n<input type=\"radio\" name=\"workcompfiled\" id=\"workcompfiledNo\"><label for=\"workcompfiledno\">No<\/label><\/td>\n<td><input type=\"radio\" name=\"fulltimestudent\" id=\"fulltimestudentyes\"><label for=\"fulltimestudentyes\">Yes<\/label>\n<input type=\"radio\" name=\"fulltimestudent\" id=\"fulltimestudentno\"><label for=\"fulltimestudentno\">No<\/label>\n<\/td>\n<\/tr>\n<tr class=\"labels\">\n<td colspan=\"2\" class=\"labels\"><label>Name of School if enrolled:<\/label><\/td>\n<td colspan=\"3\" class=\"labels\"><label>Address of School if enrolled:<\/label><\/td>\n<\/tr>\n<tr class=\"data\">\n<td class=\"data\" colspan=\"2\">\n<input id=\"school\" name=\"school\" size=\"60\" maxlength=\"75\"><\/td>\n<td class=\"data\" colspan=\"3\">\n<input id=\"schooladdr\" name=\"schooladdr\" size=\"70\" maxlength=\"85\"><\/td>\n<\/tr>\n<\/tr>\n<tr class=\"labels\">\n<td colspan=\"2\" class=\"labels\"><label>Is the insured or patient covered under any other plan?<\/label><\/td>\n<td class=\"labels\"><label>If yes, provide Policy Number:<\/label><\/td>\n<td class=\"labels\"><label>Last Name:<\/label><\/td>\n<td class=\"labels\"><label>First Name:<\/label><\/td>\n<\/tr>\n<tr class=\"data\">\n<td colspan=\"2\"><input type=\"radio\" name=\"otherins\" id=\"otherinsyes\"><label for=\"otherinsyes\">Yes<\/label>\n<input type=\"radio\" name=\"otherins\" id=\"otherinsno\"><label for=\"otherinsno\">No<\/label><\/td>\n<td>\n<input id=\"otherpolicy\" name=\"otherpolicy\" size=\"15\" maxlength=\"15\"><\/td>\n<td>\n<input id=\"otherpolicylname\" name=\"otherpolicylname\" size=\"25\" maxlength=\"25\"><\/td>\n<td>\n<input id=\"otherpolicyfname\" name=\"otherpolicyfname\" size=\"15\" maxlength=\"15\"><\/td>\n<\/tr>\n<tr style=\"background-color:lightgrey\"><td colspan=\"5\"><label><strong>ASSIGNMENT OF BENEFITS<strong><\/label><\/td>\n<\/tr>\n<tr style=\"text-align:left\">\n<td colspan=\"2.5\"><label style=\"font-weight:bold\">AUTHORIZATION TO RELEASE INFORMATION:<\/label><br>I hereby authorize any insurance company, prepayment organization, employer, hospital or physician to release all information with respect myself or any of my dependents which may have a bearing on the benefits payable under this or any other plan providing benefits. I certify the information provided is true and correct to the best of my knowledge. <\/td>\n<td colspan=\"3.5\"><label style=\"font-weight:bold\">AUTHORIZATION TO PAY BENEFITS TO PROVIDER(S):<\/label><br>\nI hereby authorize payment of benefits directly to Providers submitting claims on my behalf. This payment shall not exceed my indebtedness to the Providers and I have agreed to pay, in a current manner, any charges determined to be not covered by the plan benefits.<\/td>\n<\/tr>\n<tr style=\"background-color:lightgrey\"><td colspan=\"5\"><label><strong>PART 2: TO BE COMPLETED BY PROVIDER OF SERVICE<strong><\/label><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2.5\"><label style=\"font-weight:bold\">REPORT OF SERVICES (OR ATTACH AN ITEMIZED BILL)<\/label><\/td>\n<td colspan=\"3.5\"><label style=\"font-weight:bold\">Date patient first consulted yo for this condition:<\/label><input id=\"initialDt\" name=\"initialDt\" maxlength=\"15\" size=\"15\" placeholder=\"MM\/DD\/YYYY\" required><\/td>\n<\/table>\n\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"<p>PROVIDER SUPPORT1.855.275.1270, OPTION 4 MEDICAL CLAIM FORMForward Form and Bills to:JIPA Network\/ClaimsPO BOX 2788Kennesaw, GA 30156-9114 USAfax: 1.770.810.3789email: claims@jipanetwork.com Group\/Plan Name or Number: Insured&#8217;s ID Number: PART 1: MUST BE COMPLETED BY INSURER Insured&#8217;s Last Name: First: Middle: Patient&#8217;s Birth Date: Patient&#8217;s ID Number: Patient&#8217;s Last Name: First: Middle: Patient&#8217;s Gender: Patient&#8217;s Relationship to Insured: [&hellip;]<\/p>\n","protected":false},"author":128,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/mportal.jipanetwork.com\/index.php?rest_route=\/wp\/v2\/pages\/5835"}],"collection":[{"href":"https:\/\/mportal.jipanetwork.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mportal.jipanetwork.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mportal.jipanetwork.com\/index.php?rest_route=\/wp\/v2\/users\/128"}],"replies":[{"embeddable":true,"href":"https:\/\/mportal.jipanetwork.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=5835"}],"version-history":[{"count":68,"href":"https:\/\/mportal.jipanetwork.com\/index.php?rest_route=\/wp\/v2\/pages\/5835\/revisions"}],"predecessor-version":[{"id":5903,"href":"https:\/\/mportal.jipanetwork.com\/index.php?rest_route=\/wp\/v2\/pages\/5835\/revisions\/5903"}],"wp:attachment":[{"href":"https:\/\/mportal.jipanetwork.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=5835"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}