21. Principal source of payment

The primary source of payment for the delivery at the time of delivery:

• Private insurance
  (Blue Cross/Blue Shield, Aetna, etc.)
• Medicaid
  (or a comparable state program)
• Self-pay
  (no third party identified)
• Other
  (Indian Health Service; CHAMPUS or TRICARE; other government [federal, state, or local]; or charity)

The principal source of payment is important public health information and is needed to monitor access to care during delivery.

Check the box that best describes the primary source of payment for this delivery. If more than one source of payment for the delivery is recorded, choose the source that appears to pay for most of the delivery.

Check the source of payment for the delivery, not the payer for the newborn care or prenatal care, if different.

If “other” is checked, specify the payer.

If the principal source of payment is not known, enter “unknown” in the space.

If unsure what source of payment a given insurance falls under, check with the billing office.

1st  Hospital face sheet

2nd  Admitting office face sheet