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Loading...Download CMS Claim Form 1500 which is used by health care professionals to bill Medicare and Medicaid. In addition to Medicare parts A/B and for Medicare durable medical equipment Administrative Contractors. Claims must be made within 12 months after services are provided.
How To Write
Step 1 – Section 1 – Complete the information in the following blocks:
- 1. Select the insurance group you are using and check the box that applies
- 1.a. – Provide the insured’s ID number
- 2. Patient’s Name (last, first, middle initial)
- 3. Patient’s Date of Birth (mm/dd/yyyy)
- Sex (check one)
- 4. Insured’s Name (last, first, middle initial)
- 5. Patient’s Address( number and street)- City, State, Zip and telephone number (including area code)
- 6. Patient’s relationship to insured
- 7. Insured’s Address (number and street)-City, State, Zip and telephone number (including area code)
- 8. Patient (marital) Status (check one)
- 9. Other Insured’s Name (last, first, middle initial)
- 9a. Other Insured’s Policy or Group Number
- b. Other Insured’s Date of Birth (mm/dd/yyyy)
- sex (check one)
- 9c. Employer’s name or School name
- 9d. Insurance plan name or Program name
- 10. Is patient’s condition related to (current or previous) (check the box(s) that apply)
- 11. Insured’s Policy Group or FECA Number
- 11a. Insured’s Date of Birth (mm/dd/yyyy)
- Sex (check one)
- 11b. Employer’s name or School name
- 11c. Insurance plan name or Program name
- 11d. Is there another health benefit plan? (check one- if yes return to and complete 9 athrough d)
- 12. Read the back of the form prior to completing and signing this form – Once the information has been reviewed, place your signature on the line and enter the date mm/dd/yyyy
- 13. Insured’s or Authorized Person’s signature
Step 2 – Information Regarding Patient Illness or Injury
- 14. Date of current (mm/dd/yyyy) illness, injury, pregnancy etc.
- 15. If the patient has or has had the same or similar illness give the first date – mm/dd/yyyy
- 16. Dates patient will be unable to work in current occupation
- From: mm/dd/yyy to mm/dd/yyyy
- 17. Name of referring provider or other source
- 17a. (source)
- 17b. NPI
- 18. Hospitalization Dates related to current services
- From: mm/dd/yyyy – To: mm/dd/yyyy
- 19. RESERVED FOR LOCAL USE
- 20. Outside Lab? (yes or no) What are the charges?
- 21.Diagnosis or Nature of Illness or Injury (relate items 1.2.3 or 4 to item 24 E by line
- 22. Medicaid Resubmission
- 23. Prior Authorization Number
Step 3 – Section 24- Complete 24a. through 24j.
- 25. Federal Tax ID Number (SSN or EIN)
- 26. Patient’s Account Number
- 27. Accept Assignment? (check yes or no)
- 28. Total Charge
- 29. Amount Paid
- 30. Balance Due
- 31. Signature and Date mm/dd/yyyy
- 32. a. and b. Service of Facility Location Information
- 33. a. and b. Billing Provider Information and Phone Number (with area code)