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CMS-1500 form 1-33
| Question | Answer |
|---|---|
| Block 1 | Type of Insurance |
| Block 1 a | Insured's Id number |
| Block 2 | Patients name |
| Block 3 | Patients Date of Birth, Sex |
| Block 4 | Insured's name |
| Block 5 | Patients Address |
| Block 6 | Patients relationship to insured |
| Block 7 | Insured's address |
| Block 8 | 8 blank NUCC |
| Block 9 | Medigap |
| Block 9 a | Other insureds policy number |
| Block 9 b | 9b blank NUCC |
| Block 9 c | 9c blank NUCC |
| block 10 a,b,c | Is patients condition related to. a, employment, b, auto accident, c, other accident. |
| Block 10 d | 10d claim codes Blank NUCC |
| Block 11 | Insureds Policy Group or FECA number |
| Block 11 a | Insureds Date of Birth, Sex |
| Block 11 b | 11b Blank NUCC |
| Block 11 c | Insurance Plan Name |
| Block 11 d | Is there another Health Benefit Plan Question |
| Block 12 | Patient or Authorized Signature allowing release of medical information |
| Block 13 | AOB Assignment of Benefits. Authorizes payments of medical benefit to the undersigned physician or supplier for services |
| Block 14 | Date of Current Illness, Injury or Pregnancy |
| Block 15 | Other Date |
| Block 16 | Dates patient unable to work in current occupation |
| Block 17 | Name of Referring Provider or other source |
| Block 17 a | 17a Blank |
| Block 17 b | NPI number |
| Block 18 | Hospitalization dates related to current services |
| Block 19 | 19 Blank NUCC |
| Block 20 | Outside Lab |
| Block 21 | Diagnosis or nature of illness |
| Block 22 | Resubmission Code |
| Block 23 | Prior authorization number |
| Block 24 a | Dates of Service |
| Block 24 b | Place of Service |
| Block 24 c | EMG |
| Block 24 d | Procedures, Services, or Supplies |
| Block 24 e | Diagnosis Pointer |
| Block 24 f | Charges |
| Block 24 g | Days or Units |
| Block 24 h | Family Plan |
| Block 24 i | Id Qualifier |
| Block 24 j | Rendering Physician ID number |
| Block 25 | Federal Tax ID number |
| Block 26 | Patients Account Number |
| Block 27 | Accept Assignment |
| Block 28 | Total Charges |
| Block 29 | Amount Paid |
| Block 30 | 30 blank NUCC |
| Block 31 | Signature of Physician or supplier |
| Block 32 | Service Facility location |
| Block 32 a | Service Provider NPI |
| Block 32 b | 32b Blank |
| Block 33 | Billing Provider Info |
| Block 33 a | Billing Provider NPI |
| Block 33 b | 33b Blank |
Created by:
Leiannlg
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