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CMS-1500 Form
Blocks 1 through 13
| Question | Answer |
|---|---|
| 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 11 d | IS THERE ANOTHER HEALTH BENEFIT PLAN . QUESTION ????? |
| 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
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