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Download the Fillable HCFA 1500 Claim Form that is both a fillable and/or printable medical claim form that will provide insurance, illness and injury information for medical services claims. If the user would like to complete the form online, simply download, click inside the box to begin and begin typing your information. If the user prefers to hand-write the information, print the form and fill it out by hand.

How To Write

Step 1 – Section 1 – Patient Information –

  • 1a -Begin by entering the insured’s ID number under the appropriate insurer then continue to complete all of the blocks as follows:
  • 2 – Patient name
  • 3- Patient’s Date of Birth mm/dd/yyyy and indicate if patient is male or female
  • 4 – Insured’s Name (last, first, MI)
  • 5 – Patient’s address (number, street)
  • 6 – Patient relationship to insured
  • 7 – Insured’s address (number, street) – City, State, Zip and telephone number with area code
  • 8 – Reserved for NUCC Use
  • 9 – Other insured’s name (last, first, MI)
  • 9a – Other insured’s policy or group number
  • 9b and 9c – Reserved For NUCC Use
  • 9d – Insurance plan name or program name
  • 10 – Is patient’s condition related to – enter an X next to yes or no from a through c in the number 10 block
  • 11 – Insured’s policy number, group or FECA number
  • 11a – Insured’s date of birth mm/dd/yyyy and place an X next to the sex of the insured
  • 11b – Other claim ID provided by NUCC
  • 11c – Insurance plan or program name
  • 11d – Is there another health insurance plan (yes or no)
  • 12- Read the information in box 12 referring to the agreement to release medical information and granting permission for the insurance company to pay the provider- Then provide signature and date
  • 13 – Insured’s or authorized signer must read block 13 and provide signature

Step 2 – Section 2 – Provider Information –

  • 14 – Date of current illness, injury or pregnancy
  • 15 – Other Date mm/dd/yyyy
  • 16 – Dates patient is unable to work in current occupation
  • 17 – Name of referring provider or other source
  • 18 – Hospitalization dates related to current services
  • 19 – Additional claim information (designated by NUCC)
  • 20 – Outside Lab? What are the charges?
  • 21 – Diagnosis or nature of illness or injury
  • 22 –  Resubmission code and original ref. number
  • 23 – Prior authorization number
  • 24a – Dates of service
  • 24b -Place of service
  • 24c – EMG
  • 24d – Procedures, services or supplies (explain if any unusual procedures have been performed)
  •  24e – Diagnosis pointer
  • 24f – Charges
  • 24g – Days or units
  • 24h – Family plan
  • 24i – ID Qual.
  • 24j – Rendering provider number
  • 25 – Federal Tax ID – EIN or SSN
  • 26 -Patient’s accounting number
  • 27 – Accept assignment?
  • 28 – Total charge
  • 29- Total paid
  • 30 – Balance due
  • 31 – Signature of physician or provider, complete with degrees and/or credentials – SIgnature and Date
  • 32. Service facility location information
  • 33 – Billing provider information and telephone number

 

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