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CMS-1500 block
CMS-1500 form locators
| block | description |
|---|---|
| 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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