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CMS-1500 Form
25-33
Question | Answer |
---|---|
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 |