Compare the completed claim form to the patient's medical documentation for the submission of the claim to the secondary insurance. Indicate whether the Blocks are either correctly completed (including the correct information and formatting) or incorrectly completed (with incorrect information and/or formatting). Block 1 Correct Incorrect Block 1a Correct Incorrect Block 2 Correct Incorrect Block 3 Correct Incorrect Block 4 Correct Incorrect Block 5 Correct Incorrect Block 6 Correct Incorrect Block 7 Correct Incorrect Block 9 Correct Incorrect Block 10 Correct Incorrect Block 11 Correct Incorrect Block 12 Correct Incorrect Block 13 Correct Incorrect Block 14 Correct Incorrect Block 20 Correct Incorrect Block 21 Correct Incorrect Block 24, Line 1 Correct Incorrect Block 24, Line 2 Correct Incorrect Block 25 Correct Incorrect Block 26 Correct Incorrect Block 27 Correct Incorrect Block 28 Correct Incorrect Block 29 Correct Incorrect Block 30 Correct Incorrect Block 32 Correct Incorrect Block 33 Correct Incorrect