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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)

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