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HCFA-1500 aka. CMS-1500

 

 

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Header information

1 - Ins Type

1a - Insureds ID Number

2 - Patient's Name

3 - Patient's Birth Date

4 - Insured's Name

5 - Patient's Address

6 - Patient's Relationship to Insured

7 - Insured's Address

8 - Patient Status

9 - Other Insured's Name

9a - Other Insured's Policy or Group Number

9b - Other Insured's Date of Birth

9c - Employer's Name or School Name

9d - Insurance Plan Name or Program Name

10a through c - Is Patient's Condition Related to:

10d - Reserved for Local Use

11 - Insured's Policy Group or FECA Number

11a - Insured's Date of Birth

11b - Employer's Date of Birth

11c - Insurance Plan Name or Program Name

11d - Is there another Health Benefit Plan?

12 - Release of Medical Information Signature

13 - Payment Authorization Signature

14 - Date of Current: Illness, Injury or Pregnancy

15 - If Patient has had same or similar illness

16 - Dates Patient unable to work in current occupation

17 and 17a- Name of Referring Physician or Other Source

18 - Hospitalization Dates Related to Current Services

19 - Reserved for Local Use

20 - Outside Lab?

21 - Diagnosis or nature of illness

22. Medicaid Resubmission Number

23 - Prior Authorization Number

24a - Date(s) of Service

24b - Place of Service

24c - Type of Service

24d - Procedures, Services or Supplies

24e - Diagnosis Code

24f - Charges

24g - Days or Units

24h through k - EPSDT Family Plan, EMG, COB and Reserved for Local Use

25 - Federal Tax ID Number

26 - Patient's Account Number

27 - Accept Assignment

28 - Total Charges

29 - Amount Paid

30 - Balance Due

31 - Signature of Physician or Supplier

32 - Name and Address of Facility Where Services were Rendered

33 - Physician's, Supplier's Billing Name, Address, PIN# and GRP#

_ADA Forms-1