Header informationHCFA-1500 aka. CMS-1500
6 - Patient's Relationship to Insured
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:
11 - Insured's Policy Group or FECA Number
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
21 - Diagnosis or nature of illness
22. Medicaid Resubmission Number
23 - Prior Authorization Number
24d - Procedures, Services or Supplies
24i & j - ID QUAL & Rendering Provider ID#
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#