760 IAC 1-23-3 Modification of forms

Sec. 3. Statements, instructions, or reports, such as those which are normally completed by claimants and policyholders, and needed in the administration of benefit payments, but not requiring information from providers, may be included on the reverse side of any of the approved forms. The approved forms shall not be changed by the addition of data elements or questions; however, the name and/or identifying symbol of the insuring or prepayment organization and/or the group policyholder and/or the professional organization furnishing the form, may be imprinted in the space provided. Unneeded data elements or sections may be deleted and the space closed-up, except as follows: Unneeded elements in the "PATIENT AND INSURED (SUBSCRIBER) INFORMATION" section of the Health Insurance Claim Form-(6-74), (Exhibit II) [ 760 IAC 1-23-2], may be deleted and the space closed; however, unneeded items in the "PHYSICIAN OR SUPPLIER INFORMATION" section must be shaded-out so that the dimensions of this section and the sequence of the elements are not altered. Further, this section must be positioned on an 8 1/2 × 11 sheet of paper so that the forms of two or more insuring or prepayment organizations may be completed together by the insertion of carbon paper between them.