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Cms 1500

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
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
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