ASR Lien Resolution Program tracking number (to be completed by ASR Lien Resolution Program specialist) Claimant Name Policyholder Name (if different) (Last Name, First Name, Middle Name) (Last Name, First Name, Middle Name) Claimant DOB (mm/dd/yyyy) Policyholder DOB (if different) (mm/dd/yyyy) Claimant SSN (xxx-xx-xxxx) Policyholder SSN (if different) (xxx-xx-xxxx) Payer/Health Plan Full Name Plan or Group Number Type of Payer (choose one): Member ID Provider Name / Location of Provider (for example: Memorial Hospital, Kentucky) Commercial Payer Provider Type Hospital Employer Health Plan Medicare Advantage TRICARE ChampVA Medicaid Medicaid Managed Care Managed Care Organization Other_________________________ Place of Service (POS) Code, 1 - 81 General Acute Rehabilitation Long Term Acute Care (LTAC) Other:_________________________________________________________________ Durable Medical Equipment, Prosthetic, Orthotics & Supplies (DMEPOS) Skilled Nursing Facility (SNF) Ambulatory Surgery Center (ASC) Comprehensive Outpatient Rehabilitation Independent Diagnostic Testing Facility Facility (CORF) (IDTF) Physician Home health agency (HHA) Hospice Clinical lab Outpatient physical therapy Other______________________________ Type of Insurance Primary Secondary Policy Coverage Dates (begin/end date) (mm/dd/yyyy - mm/dd/yyyy) Date(s) of Service (DOS) ICD-9 CM Code(s) Description of service Procedure Services / Supplies Amount paid each service date (mm/dd/yyyy) for each service (codes) for each service (for each date of service)