I am trying to Complete a Workers' Compensation as Primary CMS-1500 ClaimSelect the information needed from the case study, and enter the required information on the claim

ERIN A. HELPER, M.D. 101 Medic Drive, Anywhere, NY 12345-9874 Case Study (101) 111-1234 (Office) . (101) 111-9292 (Fax) EIN: 11-1234523 NPI: 1234567890 PATIENT INFORMATION: INSURANCE INFORMATION: Name: Public, John Q. Patient Number: 17-1 Address: 10A Senate Avenue Place of Service: Office City: Anywhere WC Insurance Plan: DFEC NY WC Claim #: BL36388 State: Zip Code: 12345-1234 FECA #: 456123789 Telephone: (101) 201-7891 WC Policyholder: BIO Laboratory Sex: Male Address: Bio Drive, Anywhere, NY 12345 Date of Birth: 10-10-1959 Relationship to Patient: Employer Occupation: Technician Employer: BIO Laboratory SSN: 252-45-9568 Patient Status Married Divorced O Single Student DIAGNOSIS INFORMATION Diagnosis Code Diagnosis Code 1. Whiplash (subsequent encounter) 8134XXD 5. 2 Motor vehicle accident (subsequent encounter) V89.9XXD 3. Place of occurrence (public highway) Y92 410 A PROCEDURE INFORMATION Description of Procedure or Service Date Code Charge 1. Established patient office visit, level 3 01-03-YY 99213 40.00 2. 3. 4. SPECIAL NOTES: Originally injured driving delivery car while working 12/29/YY. Return to work 01/04/YY. NOTE: Submit claim to workers' compensation payer. Payer Name and Address: DFEC, 21 Washington Avenue, Federal MD 100011567