Prepare the claim for this case by completing the appropriate fields in the CMS$-1500$ form provided. Accuracy is important. Please note that tabbing through the form works inconsistently; it is recommended that you click in each field for which you want to enter information. For the purposes of Connect, all dates should be entered in $8-$digit format $(xx$ in MM field; $xx$ in DD field; $xxxx$ in $YY$ field$)$ except for Item Number $24,$ where the dates should be entered in $6-$digit format $(xx$ in MM field; $xx$ in DD field; $xx$ in $YY$ field$).$ NOTES: this medical facility does not use an outside lab; the patient's chart number should be used for the patient account number; we have tried to include information you might need from earlier Case Studies, but please refer back to Chapter $7$ if necessary. Be sure to follow NUCC directions for CMS$-1500$ claim completion in regards to punctuation in addresses. Related to this, do not include punctuation for Item Number $31.$ Follow Medicare guidelines and abbreviate street addresses $($i$.$e$.$ ST rather than Street$).$ Per NUCC Guidelines, use SOF in this exercise for Signature on File if appropriate. Also, per NUCC guidelines, do not include the decimal point in the diagnosis code$($s$)$ entered in Item Number $21.$ Functionality TIP: if you can't see the entire form and don't have scroll bar functionality $($especially if you click "Check my work"$),$ click anywhere in the form and use the arrow keys on your keyboard to help you navigate.

Billing Provider: Valley Associates, PC

NPI: $1476543215$

Employer ID Number: $16-1234567$

Address: $1400$ West Center Street, Toledo, OH $43601-0213$

Telephone: $555-967-0303$

Rendering Provider: Christopher M$.$ Connolly, MD

NPI: $8877365552$

Assignment: Accepts

Signature: On File $(01/01/2029)$