Patient's birth date and gender

Patient's address, city, state, zip code and phone #

Patient's relationship to the insured

Insured's address, city, state, zip code and phone #

Other insured's policy or group number

Other insured's insurance plan or name

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CMS-1500

Block 1-13

Term	Definition
1	Coverage
1a	Insured's ID number
2	Patient's name
3	Patient's birth date and gender
4	Insured's name
5	Patient's address, city, state, zip code and phone #
6	Patient's relationship to the insured
7	Insured's address, city, state, zip code and phone #
8	Reserved for NUCC use
9	Other insured's name
9a	Other insured's policy or group number
9b	Reserved for NUCC use
9c	Reserved for NUCC use
9d	Other insured's insurance plan or name
10a-c