CMS-1500 form locators
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| 1 | INSURANCE TYPE
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| 1a. | INSURED'S I.D. NUMBER
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| 2 | PATIENT'S NAME (Last, First, Middle)
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| 3 | PATIENT'S BIRTH DATE
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| 4 | INSURED'S NAME
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| 5 | PATIENT'S ADDRESS (No., Street)
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| 6 | PATIENT RELATIONSHIP TO INSURED
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| 7 | INSURED'S ADDRESS (No., Street)
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| 8 | RESERVED FOR NUCC USE
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| 9 | OTHER INSURED'S NAME (Last, First, Middle)
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| 9a. | OTHER INSURED'S POLICY OR GROUP NUMBER
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| 9b. | RESERVED FOR NUCC USE
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| 9c. | RESERVED FOR NUCC USE
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| 9d. | INSURANCE PLAN NAME OR PROGRAM NAME
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| 10 | IS PATIENTS CONDITION RELATED TO
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| 10a. | EMPLOYMENT? (Current or Previous)
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| 10b. | AUTO ACCIDENT?
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| 10c. | OTHER ACCIDENT?
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| 10d. | CLAIM CODES (Designated by NUCC)
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| 11 | INSURED'S POLICY GROUP OR FECA NUMBER
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| 11a. | INSURED'S DATE OF BIRTH
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| 11b. | OTHER CLAIM ID (Designated by NUCC)
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| 11c. | INSURANCE PLAN NAME OR PROGRAM NAME
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| 11d. | IS THERE ANOTHER HEALTH BENEFIT PLAN?
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| 12 | PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE
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| 13 | INSURED'S OR AUTHORIZED PERSON'S SIGNATURE
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| 14 | DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP)
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| 15 | OTHER DATE
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| 16 | DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
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| 17 | NAME OF REFFERING PROVIDER OR OTHER SOURCE
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| 17a. |
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| 17b. | NPI
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| 18 | HOSPITALIZATION DATES RELATED TO CURRENT SUERVICES
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| 19 | ADDITIONAL CLAIM INFORMATION (Designated by NUCC)
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| 20 | OUTSIDE LAB?
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| 21 | DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
Relate A-L to service line below (24E)
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| 21A. |
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| 21B. |
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| 21C. |
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| 21D. |
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| 21E. |
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| 21F. |
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| 21G. |
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| 21H. |
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| 21I. |
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| 21J. |
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| 21K. |
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| 21L. |
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| 22 | RESUBMISSION CODE
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| 23 | PRIOR AUTHORIZATION NUMBER
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| 24A. | DATES OF SERVICE
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| 24B. | PLACE OF SERVICE
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| 24C. | EMG
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| 24D. | PROCEDURES, SERVICES, OR SUPPLIES
(CPT/HCPCS/MODIFIERS)
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| 24E. | DIAGNOSIS POINTER
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| 24F. | $ CHARGES
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| 24G. | DAYS OR UNITS
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| 24H. | EPSDT Family Plan
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| 24I. | ID. QUAL.
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| 24J. | RENDERING PROVIDER ID. #
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| 25 | FEDERAL TAX I.D. NUMBER
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| 26 | PATIENT'S ACCOUNT NO.
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| 27 | ACCEPT ASSIGNMENT?
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| 28 | TOTAL CHARGE
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| 29 | AMOUNT PAID
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| 30 | Rsvd for NUCC Use
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| 31 | SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS
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| 32 | SERVICE FACILITY LOCATION INFORMATION
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| 32a. | NPI
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| 32b. |
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| 33 | BILLING PROVIDER INFO & PH #
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| 33a. | NPI
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| 33b. |
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Created by:
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