Type of Health Insurance Coverage Applicable to the Claim

Patient's Address and Telephone Number

Other insured's policy or group number

Patient's condition related to:

Insured's policy group or FECA number

Name of Referring Provider or Other Source

Diagnosis or Nature of Illness or Injury

Procedures, Services, or Supplies code

Patient's Account Number (if desired)

Signature of Physician or Supplier

Service Facility Location Information

Patient's Condition and the Provider's Information

Patient's Relationship to Insured

Insurance Primary to Medicare, Insured's Address and Telephone number

Patient's or Authorized Person's Signature

Medigap Benefits, Insured/Authorized Person's Signature

Dates Patient Unable to Work in Current Occupation

Service Furnished as a Result of, or Subsequent to, a Related Hospitalization

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CMS 1500

Block numbers and descriptions

Term	Definition
Box 1	Type of Health Insurance Coverage Applicable to the Claim
Box 2	Patient's Name
Box 3	Patient's Birth Date
Box 4	Insured's Name
Box 5	Patient's Address and Telephone Number
Box 9	Other Insured's Name
Box 9a	Other insured's policy or group number
Box 10a-c	Patient's condition related to:
Box 11	Insured's policy group or FECA number
Box 11a	Insured's Date of Birth
Box 11b	Employer's Name or School Name
Box 14	Date of Current Illness
Box 17	Name of Referring Provider or Other Source
Box 17b	Referring Physician's NPI
Box 19	Reserved for Local Use
Box 21	Diagnosis or Nature of Illness or Injury
Box 24a	Date of Service
Box 24b	Place of Service
Box 24d	Procedures, Services, or Supplies code
Box 24e	Diagnosis Pointer
Box 24f	Charges
Box 24g	Days or Units
Box 24j	Rendering Provider NPI
Box 25	Federal Tax ID Number
Box 26	Patient's Account Number (if desired)
Box 27	Accept Assignment
Box 28	Total charge
Box 29	Dollar Amount
Box 31	Signature of Physician or Supplier
Box 32	Service Facility Location Information
Box 32a	Service Facility NPI
Box 33	Billing Provider
Box 33a	Billing Provider NPI
Block 1-13	Patient Demographics
Blocks 14-33	Patient's Condition and the Provider's Information
Box 1a	Insured's ID Number
Box 6	Patient's Relationship to Insured
Box 7	Insurance Primary to Medicare, Insured's Address and Telephone number
Box 8	Reserved for NUCC use
Box 9b	Reserved for NUCC use
Box 9c	Reserved for NUCC use
Box 9d	Insurance Plan/Program Name
Box 11c	Insurance Plan/Program Name
Box 11d	Leave Blank
Box 12	Patient's or Authorized Person's Signature
Box 13	Medigap Benefits, Insured/Authorized Person's Signature
Box 15	Leave Blank
Box 16	Dates Patient Unable to Work in Current Occupation
Box 17a	Leave Blank
Box 18	Service Furnished as a Result of, or Subsequent to, a Related Hospitalization
Box 20	Diagnostic and Purchased Test
Box 21	Patient's Diagnosis/Condition
Box 22	Leave Blank
Box 23	Prior Authorization Number
Line 24	Service Line
Box 24c	Leave Blank
Box 24h	Leave Blank
Box 24i	ID Qualifier
Box 30	Leave Blank
Box 32b	ID Qualifier or PIN

Created by: rose731red

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