Sample 1500 Health Insurance Form

In addition to medicare parts a b and for medicare durable medical equipment administrative contractors.

Sample 1500 health insurance form. Approved omb 0938 1197 form 1500 02 12 1a. The cms 1500 form is the health insurance claim form used for submitting physician and professional claims for providers. Insured s policy group or feca number a. Number for program in item 1 4.

Approved omb 093b 1197 form cms 1500 06 15 omb no. 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. Until march 31 2014 one can use either the old cms 1500 claim form version 08 05 as marked in the lower right hand corner or the new cms 1500 version 02 12 for paper claims submitted to medicare bcbs and bhs. Item 1a insured s id number patient s medicare health insurance claim number.

Download cms claim form 1500which is used by health care professionals to bill medicare and medicaid. Cms 1500 form item instructions item 1 type of health insurance coverage applicable to the claim show the type of health insurance coverage applicable to this claim by checking the appropriate box e g if a medicare claim is being filed check the medicare box. I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me or were furnished. Insured s address no street city state zip code telephone include area code 11.

Champus is not a health insurance program but makes payment for health benefits provided through certain affiliations with the uniformed services. Sample form information and instructions for form cms 1500 02 12 for all insurance companies. Insured s name last name first name middle initial 7. Continue to use the current cms form 1500 02 12 beyond the o m b.

Expiration date of 2020 03 31 pending o m b.