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CMS-1500 Form

Blocks 1 through 13

Block 1 Type of Insurance
Block 1 a Insured's ID Number
Block 2 Patients Name
Block 3 Patient's Birth Date and Sex
Block 4 Insured's Name
Block 5 Patients Address
Block 6 Patients relationship to Insured
Block 7 Insured's Address
Block 8 Reserved for NUCC use 8
Block 9 Medigap
Block 9 a Other insured's Policy, Group Number (Medigap)
Block 9 b Reserved for NUCC 9b Leave Blank
Block 9 c Reserved for NUCC 9c Leave Blank
Block 9 d Insurance Plan Name (Medigap)
Block 10 a,b,c Is patients condition related to, A employment, B auto accident, C other accident
Block 11 Insured's policy group or FECA number
Block 11 a Insured's Date of birth, Sex
Block 11 b Other Claim ID Designated by NUCC Blank 11b
Block 11 c Insurance Plan Name
Block 12 Patients or Authorized person's signature. Authorize the release of any Medical or other information necessary to process this claim.
Block 13 AOB- Assignment of Benefits Insured's or Authorized person's signature. Authorizes payments of medical benefits to the undersigned physician or supplier for services described below.
Block 10 d Claim Codes Designated By NUCC 10 d Leave Blank
Created by: Leiannlg