Medical Insurance Claim Form 1500

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.

Medical insurance claim form 1500. The form is used by physicians and allied health professionals to submit claims for medical services. Authorizes any entity to release to medicare medical and nonmedical information including employment status and whether the person has employer group health insurance liability no fault worker s compensation or other insurance which is responsible to pay for the services for which the medicare claim is made. In addition to medicare parts a b and for medicare durable medical equipment administrative contractors. Listed on this page are the cms1500 claim form place of service codes and descriptions.

Fillable 1500 health inusrance claim form. Insured s policy group or feca number. These codes should be used on medicare and insurance company cms1500 claim forms to specify the entity where service s procedure s were rendered. Download cms claim form 1500which is used by health care professionals to bill medicare and medicaid.

Insured s name last name first name middle initial 7. If the user would like to complete the form online simply download click inside the box to begin and begin typing your information. Expiration date of 2020 03 31 pending o m b. Insured s address no street 11.

06 30 2021 instructions for completing owcp 1500 health insurance claim form for medical services provided under the federal employees compensation act feca the black lung benefits act blba and the energy employees occupational illness compensation program act of 2000 eeoicpa. Instructions for completing the cms 1500 claim form the center of medicaid and medicare services cms form 1500 must be used to bill sfhp for medical services. All items must be completed unless otherwise noted in these instructions.