“Medicare, Medicaid, TRICARE, CHAMPVA, Group Health Plan, FECA, Black Lung, Other” means the insurance type to which the claim is being submitted. “Other” indicates health insurance including HMOs, commercial insurance, automobile accident, liability, or workers’ compensation. This information directs the claim to the correct program and may establish primary liability.

INSTRUCTIONS: Indicate the type of health insurance coverage applicable to this claim by placing an X in the appropriate box. Only one box can be marked.