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Cms 1500
| Question | Answer |
|---|---|
| Block1. | Medicare box |
| Block1a | Insurance ID number |
| Block2. | Patient name (last name, first name, Middle initial) |
| Block3. | patient birth date/sex |
| Block4. | Insurance name (last name, first name, middle initial) |
| Block5 | Patient address , city, state , zip code, Telephone |
| Block6. | Patient relationship to insured |
| Block7. | Insurance address , city, state, zip code, telephone |
| Block8. | Reserved for Nucc use |
| Block9. | other insured name (last name, first name, middle initial) |
| block9a. | Other insured policy or group number |
| block9b. | Reserved for NUCC use |
| block9c. | Reserved for NUCC use |
| block9d. | Insurance plan name or program name |
| Block10 | is the patient condition related to |
| Block10a | employment |
| Block10b | auto accident |
| Block10c | other accident |
| Block10d | |
| Block11 | insurance policy group of feca number |
| Block11a | insurance date of birth / sex |
| Block11b | other claim |
| Block11c | insurance plan name or program name |
| Block11d | another health benefits plan |
| Block12 | patient or authorized person signature |
| Block13 | insurance or authorized person signature |
| Block14 | dates of current illness, injury pregnancy |
| Block15 | other date |
| Block16 | dates patent unable to work |
| Block17 | leave blank |
| Block18 | hospital date related to current service |
| Block19 | leave blank |
| Block20 | |
| Block21 | diagnosis or nature of illness or injury |
| Block22 | Resubmission number |
| Block23 | Prior authorization number |
| Block24a | dates of service |
| Block24b | place of service |
| Block24c | Emg |
| Block24d | Procedures service or supplies |
| Block24e | Diagnosis pointer |
| Block24f | $ charges |
| Block24G | Days or units |
| Block24H | EPSDT |
| Block24I | ID qual |
| Block24J | Rendering provider ID |
| Block25 | Federal Tax I.d number |
| Block26 | patients account NO. |
| Block27 | accept assignment |
| Block28 | total charge |
| Block29 | amount paid |
| Block30 | Rsvd for Nucc use |
| Block31 | Signature of physician or supplier includes degrees credential |
| Block32 | service facility location information |
| Block33 | Billing provider information & ph # |
Created by:
Jackie_20
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