Various Fillable Forms
CMS 1500 Insurance Claim form is ideal for fast professional health care claims submission. The CMS-1500 form is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims. It is also used for billing of some Medicaid State Agencies. The National Uniform Claim Committee (NUCC) is responsible for the design and maintenance of the CMS-1500 form. The only acceptable claim forms are those printed in Flint OCR Red, MoreHEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA 1. MEDICARE MEDICAID TRICARE CHAMPUS (Sponsor's SSN) CHAMPVA GROUP HEALTH PLAN (SSN or ID) FECA BLK LUNG (SSN) SEX M 5. PATIENT'S ADDRESS (No., Street) F 7. INSURED'S ADDRESS (No., Street) OTHER 1a. INSURED'S I.D. NUMBER PICA (For Program in Item 1) (Medicare #) (Medicaid #) (Member ID#) (ID) 4. INSURED'S NAME (Last Name, First Name, Middle Initial) 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3 Less
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