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CMS 1500

Block numbers and descriptions

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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