Sample Health Insurance Claim Form 1500

Insured s address no street city state zip code telephone include area code 11.

Sample health insurance claim form 1500. The health insurance claim form cms 1500 is used by allied health professionals physicians laboratories and pharmacies to bill for supplies and services provided to medi cal recipients. Information and instructions for form cms 1500 02 12 for all insurance companies. Health insurance common claims form. The ub 04 cms 1450 is a claim form used by hospitals nursing facilities in patient and other facility providers.

According to very well health the cms 1500 is the red ink on white paper standard claim form used by physicians and suppliers for claim billing. Number for program in item 1 4. Tufts does not want the new form until april 1 2014. Although it was developed by the centers for medicare and medicaid cms it has become the standard form used by all insurance carriers in short it is a health insurance claim form cms 1500.

On the other hand the hcfa 1500 cms 1500 is a medical claim form employed by individual doctors practices nurses and professionals including therapists chiropractors and out patient clinics. Block 1 show all type s of health insurance applicable to this claim by checking the appropriate box es. A federal government website managed and paid for by the u s. Approved omb 0938 1197 form 1500 02 12 1a.

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. Centers for medicare medicaid services. Claims must be made within 12 months after services are provided.

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. Insured s date of birth b. Insured s policy group or feca number a. 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.

7500 security boulevard baltimore md 21244. Notes comments addresses or any other notations in this area of the form will result in the claim being returned unprocessed. For medical assistance processing the top right side of the cms 1500 must be blank.