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CMS-1500 block

CMS-1500 form locators

blockdescription
1 INSURANCE TYPE
1a. INSURED'S I.D. NUMBER
2 PATIENT'S NAME (Last, First, Middle)
3 PATIENT'S BIRTH DATE
4 INSURED'S NAME
5 PATIENT'S ADDRESS (No., Street)
6 PATIENT RELATIONSHIP TO INSURED
7 INSURED'S ADDRESS (No., Street)
8 RESERVED FOR NUCC USE
9 OTHER INSURED'S NAME (Last, First, Middle)
9a. OTHER INSURED'S POLICY OR GROUP NUMBER
9b. RESERVED FOR NUCC USE
9c. RESERVED FOR NUCC USE
9d. INSURANCE PLAN NAME OR PROGRAM NAME
10 IS PATIENTS CONDITION RELATED TO
10a. EMPLOYMENT? (Current or Previous)
10b. AUTO ACCIDENT?
10c. OTHER ACCIDENT?
10d. CLAIM CODES (Designated by NUCC)
11 INSURED'S POLICY GROUP OR FECA NUMBER
11a. INSURED'S DATE OF BIRTH
11b. OTHER CLAIM ID (Designated by NUCC)
11c. INSURANCE PLAN NAME OR PROGRAM NAME
11d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
12 PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE
13 INSURED'S OR AUTHORIZED PERSON'S SIGNATURE
14 DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP)
15 OTHER DATE
16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
17 NAME OF REFFERING PROVIDER OR OTHER SOURCE
17a.
17b. NPI
18 HOSPITALIZATION DATES RELATED TO CURRENT SUERVICES
19 ADDITIONAL CLAIM INFORMATION (Designated by NUCC)
20 OUTSIDE LAB?
21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E)
21A.
21B.
21C.
21D.
21E.
21F.
21G.
21H.
21I.
21J.
21K.
21L.
22 RESUBMISSION CODE
23 PRIOR AUTHORIZATION NUMBER
24A. DATES OF SERVICE
24B. PLACE OF SERVICE
24C. EMG
24D. PROCEDURES, SERVICES, OR SUPPLIES (CPT/HCPCS/MODIFIERS)
24E. DIAGNOSIS POINTER
24F. $ CHARGES
24G. DAYS OR UNITS
24H. EPSDT Family Plan
24I. ID. QUAL.
24J. RENDERING PROVIDER ID. #
25 FEDERAL TAX I.D. NUMBER
26 PATIENT'S ACCOUNT NO.
27 ACCEPT ASSIGNMENT?
28 TOTAL CHARGE
29 AMOUNT PAID
30 Rsvd for NUCC Use
31 SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS
32 SERVICE FACILITY LOCATION INFORMATION
32a. NPI
32b.
33 BILLING PROVIDER INFO & PH #
33a. NPI
33b.
Created by: 1berev2
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