Interactive CMS-1500 Claim Form Instructions
 
How to use the Interactive Claim Form:
  • Click on a item on the form below to view detailed electronic and paper instructions.
  • The following instructions apply to both electronic and paper claim submitters. Instructions include requirements for each item of the CMS-1500 claim form.
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CMS-1500 claim form header spacer
Left Side of CMS-1500 Claim Form Item 1: Type of Health Insurance Item 1a: Insured's I.D. Number Right Side of CMS-1500 Claim Form spacer
Item 2: Patient's Name Item 3: Patient's Birth Date Item 4: Insured's Name spacer
Item 5: Patient's Address Item 6: Patient's Relationship To Insured Item 7: Insured's Address spacer
Item 8: Patient Status spacer
Item 9, 9a, 9b, 9c, 9d: Other Insured's Name, Policy Number, Date of Birth, Employer's Name/School, & Insurance Plan Name/Program Name Item 10: Is The Patient's Condition Related To Employment, Auto Accident, or Other Accident? Item 11, 11a, 11b, 11c, 11d: Insured's Policy Number, Date of Birth, Employer's Name/School, & Is There Another Health Benefit Plan spacer
Item 10d: Reserved For Local Use spacer
Item 12: Patient's or Authorized Person's Signature Item 13: Insured's or Authorzied Person's Signature spacer
Item 14: Date of current illness, injury, date of the initiation chiropractic course of treatment and x-ray date. Item 15: If The Patient Has Had Same Or Similar Services/ Illness - Give First Date Item 16: Dates Patient Unable To Work In Current Occupation spacer
Items 17, 17a, & 17b: Referring Physician Or Other Source Information Item 18: Hospitalization Dates Related To Current Services spacer
Item 19: Reserved for Local Use Item 20: Outside Lab - Charges spacer
Item 21: Diagnosis or Nature or Illness or Injury Item 22: Medicaid Resubmission Code spacer
Item 23: Prior Authorization Number spacer
Item 24a: Claim Detail Information Items 24b: Place of Service Item 24c: Type of Service Item 24d: Providers, Services, or Supplies Item 24e: Diagnosis Code Item 24f: Charges Item 24g: Days or Units Item 24h: EPSDT Family Plan Item 24i: Legacy Qualifier Rendering Provider Item 24j: Legacy Provider Number (PTAN)/NPI Rendering Provider spacer
Item 25: Federal Tax I.D. Number Item 26: Patient's Account Number Item 27: Accept Assignment Item 28: Total Charges Item 29: Amount Paid Item 30: Balance Due spacer
Item 31: Signature of Physician or Supplier Item 32, 32a, & 32b: Name & Complete Address of Facility (Including Zip Code) Where Services Were Rendered Items 33, 33a, & 33b: Physician's/Supplier's Billing Information spacer
Footer of CMS-1500 Claim Form spacer


CPT codes, descriptions, and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.