Attachement B: CMS - 1500 Form Example

ATTACHMENT B - CMS - 1500 Form Example (pdf)

Textual Description:

1-13 on Top Image, 14-33 on Bottom Image

1. Insurance - Check your type of Insurance and fill 1a. with number based upon which one you check:
   1. Medicare - 1a: Medicaid Number
   2. Tricare CHAMPUS- 1a: Sponsor's SSN
   3. CHAMPVA- 1a: Member ID#
   4. Group Health Plan- 1a: SSN or ID
   5. FECA Black Lung- 1a: SSN
   6. Other- 1a: ID
2. Patient's Name (Last Name, First Name, Middle Initial)
3. Patient's Birth Date (MM DD YY) and Sex
4. Insured's Name (Last Name, First Name, Middle Initial)
5. Patient's Address (Number, Street), City, State, Zip and Telephone in boxes below
6. Patient's Relationship to Insured
   1. Self
   2. Spouse
   3. Child
   4. Other
7. Insured's Address (Number, Street) City, State, Zip and Telephone in boxes below
8. Patient Status
   1. Single, Married or Other
   2. Employed, Full-Time Student, Part-Time Student
9. Other Insured's Name (Last Name, First Name, Middle Initial)
   1. Other Insured's Policy or Group Number
   2. Other Insured's Date of Birth (MM DD YY) & Sex
   3. Employer's Name or School Name
   4. Insurance Plan or Program Name
10. Patient's Condition Related to:
    1. Employment? (Current or Previous) (Yes / No)
    2. Auto Accident? (Yes / No) & State
    3. Other Accident? (Yes / No)
11. Insured's Policy Group or FECA Number
    1. Insured's Date of Birth (MM DD YY) & Sex
    2. Employer's Name or School Name
    3. Insurance Plan or Program Name
    4. Is there another health benefit plan? (If yes, return to and complete item 9)
12. Patient's or Authorized Person's Signature
    I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.
13. Insured or Authorized Person's Signature
    I authorize payment of medical benefits to the understigne physician or supplier for services described below.

14. Date of Current (MM DD YY)
    • Illness (First Symptom)
    • Injury (Accident)
    • Pregnancy (LMP)
15. If patient has had same or similar illness, give first date (MM DD YY)
16. Dates patient unable to work in current occupation From (MM DD YY) To (MM DD YY)
17. Name of referring Physician or other source
    1. ID Number of Referring Physician
18. Hospitalization dates related to current services: From (MM DD YY) To (MM DD YY)
19. Reserved For Local Use [Example shows: Associate Provider Name (if applicable)]
20. Outside Lab?
    • Yes / No
    • $ Charges
21. Diagnosis or Nature of Illness or Injury (Relate items 1,2,3 or 4 to Item 24 E)
22. Medicaid Resubmission Code & Original Ref No.
23. Prior Authorization Number
24. Table listing dates of service and codes & costs related to those dates of service
    1. Date(s) of Service: From - (MM DD YY) To - (MM DD YY)
    2. Place of Service
    3. Type of Service
    4. Procedures, Services or Supplies
       Explain unusual circumstances
       OPT / HCPCS & Modifier
    5. Diagnosis Code
    6. $ Charges
    7. Days or Units
    8. EPSDT Family Plan
    9. EMG
    10. COB
    11. Reserved for Local Use
25. Federal Tax ID Number
    • Check box asking if it is SSN
    • Check box asking if it is EIN
26. Patient's Account Number
27. Accept Assignment?
    (For government claims, see back) (Yes, No)
28. Total Charge
29. Amount Paid
30. Balance Due
31. Signature of Physician or Supplier Including Degrees or Credentials
    (I certify that the statements on the reverse apply to this bill and are made a part thereof.)
    Signature line and Date Line
32. Name and addresss of facility where services were rendered (if other than home or office)
33. Physician's Supplier's Billing Name, Address, Zipcode and Phone
    PIN # / GRPs