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CMS-1500 Form

25-33

QuestionAnswer
Block 25 Federal Tax ID Number
Block 26 Patients Account Number
Block 27 Accepts Assignments Yes or No
Block 28 Total Charge
Block 29 Amount Paid
Block 30 Blank NUCC
Block 31 Signature of Physician or Supplier and Date
Block 32 Service Facility Location Information
Block 32 a Service Provider NPI Number
Block 32 b Blank
Block 33 Billing Provider Info & Phone #
Block 33 a Billing Providers NPI Number
Block 33 b Blank
Created by: Leiannlg