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CMS-1500 form 1-33

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