CMS-1500 (02-12), Health Insurance Claim Form (NUCC Approved) (OMB 0938-1197) Instructions
This form contains 252 fields organized into 32 sections, giving it a Form Complexity Index of 73/100 (complex). Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Claim Info & Outside Lab (Items 19-20) | ||
| Additional Claim Information | Text |
Enter any additional claim information or remarks designated by NUCC that apply to this claim.
|
| Outside Lab: Yes | Checkbox |
Check this box if the lab work for this claim was performed by an outside (non-office) laboratory.
|
| Outside Lab: No | Checkbox |
Check this box if the lab work for this claim was not performed by an outside laboratory.
|
| Item 20 - Outside Lab Charges (Dollars) | Text |
Dollar portion of the purchased outside-lab charge, digits only, with no dollar sign or decimal point. Leave blank when Outside Lab is No. Never write Yes or No in this box.
Example: 18
|
| Item 20 - Outside Lab Charges (Cents) | Text |
Two-digit cents portion of the purchased outside-lab charge. Leave blank when Outside Lab is No.
Example: 00
|
| Another Health Benefit Plan (11d) | ||
| Yes | Checkbox |
Check this box if the patient is covered by another health benefit plan in addition to the plan listed on this claim.
|
| No | Checkbox |
Check this box if the patient is not covered by any other health benefit plan besides the plan listed on this claim.
|
| Billing Provider Info & Phone (Item 33) | ||
| Billing Provider Phone Area Code | Text |
Enter the area code portion of the billing provider’s phone number.
|
| Billing Provider Phone Number | Text |
Enter the remaining digits of the billing provider’s phone number.
|
| Billing Provider Name and Address | Text |
Enter the billing provider’s name and mailing address (and other identifying details as needed) as shown in Item 33.
|
| Billing Provider NPI (33a) | Text |
Enter the billing provider’s National Provider Identifier (NPI).
|
| Billing Provider Other ID (33b) | Text |
Enter the billing provider’s other identifier (if applicable) as required by the payer.
|
| Claim Codes (10d) | ||
| Claim Codes (10d) | Text |
Enter any applicable claim codes for this claim as designated by the NUCC.
|
| Claim Totals (Items 28-30) | ||
| Item 28 - Total Charge (Dollars) | Text |
Dollar portion of the sum of all 24F line charges, digits only, with no dollar sign, comma or decimal point. For $271.30 enter 271 here and 30 in the cents box.
Example: 271
|
| Item 28 - Total Charge (Cents) | Text |
Two-digit cents portion of the Item 28 total charge. For $271.30 enter 30, for $271.00 enter 00. This box is NOT the amount paid.
Example: 30
|
| Item 29 - Amount Paid (Dollars) | Text |
Dollar portion of the amount the patient or a primary payer has already paid on this claim. Enter 0 when nothing has been paid. Digits only.
Example: 0
|
| Item 29 - Amount Paid (Cents) | Text |
Two-digit cents portion of the amount already paid. Enter 00 when nothing has been paid.
Example: 00
|
| Diagnosis Information (Item 21) | ||
| Item 21 - ICD Indicator | Text |
Single-digit ICD code-set indicator: 0 for ICD-10-CM, 9 for ICD-9-CM. Enter exactly one digit.
Example: 0
|
| Item 21 - ICD Indicator (second box) | Text |
Second small box beside the ICD indicator. Normally left blank, because the indicator is a single digit entered in the first box. Never put a diagnosis code here.
|
| Item 21 - Diagnosis Code A | Text |
ICD-10-CM diagnosis code A, written exactly as coded including the decimal point (E11.9, I10, E78.5). Fill these boxes in order starting at A and leave the rest blank when there are fewer diagnoses.
Example: E11.9
|
| Item 21 - Diagnosis Code B | Text |
ICD-10-CM diagnosis code B, written exactly as coded including the decimal point (E11.9, I10, E78.5). Fill these boxes in order starting at A and leave the rest blank when there are fewer diagnoses.
|
| Item 21 - Diagnosis Code C | Text |
ICD-10-CM diagnosis code C, written exactly as coded including the decimal point (E11.9, I10, E78.5). Fill these boxes in order starting at A and leave the rest blank when there are fewer diagnoses.
|
| Item 21 - Diagnosis Code D | Text |
ICD-10-CM diagnosis code D, written exactly as coded including the decimal point (E11.9, I10, E78.5). Fill these boxes in order starting at A and leave the rest blank when there are fewer diagnoses.
|
| Item 21 - Diagnosis Code E | Text |
ICD-10-CM diagnosis code E, written exactly as coded including the decimal point (E11.9, I10, E78.5). Fill these boxes in order starting at A and leave the rest blank when there are fewer diagnoses.
|
| Item 21 - Diagnosis Code F | Text |
ICD-10-CM diagnosis code F, written exactly as coded including the decimal point (E11.9, I10, E78.5). Fill these boxes in order starting at A and leave the rest blank when there are fewer diagnoses.
|
| Item 21 - Diagnosis Code G | Text |
ICD-10-CM diagnosis code G, written exactly as coded including the decimal point (E11.9, I10, E78.5). Fill these boxes in order starting at A and leave the rest blank when there are fewer diagnoses.
|
| Item 21 - Diagnosis Code H | Text |
ICD-10-CM diagnosis code H, written exactly as coded including the decimal point (E11.9, I10, E78.5). Fill these boxes in order starting at A and leave the rest blank when there are fewer diagnoses.
|
| Item 21 - Diagnosis Code I | Text |
ICD-10-CM diagnosis code I, written exactly as coded including the decimal point (E11.9, I10, E78.5). Fill these boxes in order starting at A and leave the rest blank when there are fewer diagnoses.
|
| Item 21 - Diagnosis Code J | Text |
ICD-10-CM diagnosis code J, written exactly as coded including the decimal point (E11.9, I10, E78.5). Fill these boxes in order starting at A and leave the rest blank when there are fewer diagnoses.
|
| Item 21 - Diagnosis Code K | Text |
ICD-10-CM diagnosis code K, written exactly as coded including the decimal point (E11.9, I10, E78.5). Fill these boxes in order starting at A and leave the rest blank when there are fewer diagnoses.
|
| Item 21 - Diagnosis Code L | Text |
ICD-10-CM diagnosis code L, written exactly as coded including the decimal point (E11.9, I10, E78.5). Fill these boxes in order starting at A and leave the rest blank when there are fewer diagnoses.
|
| Hospitalization Dates (Item 18) | ||
| Hospitalization From - Month | Text |
Enter the month the hospitalization began (FROM date).
|
| Hospitalization From - Day | Text |
Enter the day of the month the hospitalization began (FROM date).
|
| Hospitalization From - Year | Text |
Enter the year the hospitalization began (FROM date).
|
| Hospitalization To - Month | Text |
Enter the month the hospitalization ended (TO date). Fill only if 'Hospitalization From - Day' is 'Yes'.
Depends on:
Hospitalization From - Day
|
| Hospitalization To - Day | Text |
Enter the day of the month the hospitalization ended (TO date).
|
| Hospitalization To - Year | Text |
Enter the year the hospitalization ended (TO date).
|
| Illness/Injury/Other Dates (Items 14-15) | ||
| Current Illness/Injury Date - Month | Date |
Enter the month of the date of current illness, injury, or pregnancy (LMP).
|
| Current Illness/Injury Date - Day | Date |
Enter the day of the date of current illness, injury, or pregnancy (LMP).
|
| Current Illness/Injury Date - Year | Date |
Enter the year of the date of current illness, injury, or pregnancy (LMP).
|
| Current Illness/Injury Date Qualifier | Text |
Enter the qualifier code that indicates what the date of current illness, injury, or pregnancy represents.
|
| Other Date Qualifier | Date |
Enter the qualifier code that indicates what the other date represents.
|
| Other Date - Month | Date |
Enter the month for the other date indicated by the qualifier.
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| Other Date - Day | Date |
Enter the day for the other date indicated by the qualifier.
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| Other Date - Year | Date |
Enter the year for the other date indicated by the qualifier.
|
| Insurance Program Selection | ||
| Medicare | Checkbox |
Check this box if the patient’s coverage for this claim is through Medicare.
|
| Medicaid | Checkbox |
Check this box if the patient’s coverage for this claim is through Medicaid.
|
| TRICARE | Checkbox |
Check this box if the patient’s coverage for this claim is through TRICARE.
|
| CHAMPVA | Checkbox |
Check this box if the patient’s coverage for this claim is through CHAMPVA.
|
| Group Health Plan | Checkbox |
Check this box if the patient’s coverage for this claim is through a Group Health Plan.
|
| FECA / Black Lung | Checkbox |
Check this box if the claim is covered under FECA or the Black Lung program.
|
| Other | Checkbox |
Check this box if the patient’s coverage for this claim is through another program not listed and enter the program ID number.
|
| Insured Address & Phone | ||
| Insured Street Address | Text |
Enter the insured’s street address (number and street name).
|
| Insured City | Text |
Enter the city for the insured’s mailing address.
|
| Insured State | Text |
Enter the state for the insured’s mailing address.
|
| Insured ZIP Code | Text |
ZIP Code of the insured's address, exactly as written, including any leading zero (02134) and the optional plus-four extension.
Example: 44126
|
| Insured Phone Area Code | Text |
Enter the area code for the insured’s telephone number.
|
| Insured Phone Number | Text |
Enter the insured's telephone number excluding the area code, as plain text in the format NNN-NNNN (e.g., 555-0192). Do not format as a number.
Example: 555-0192
|
| Insured Policy & Demographics | ||
| Insured Policy Group or FECA Number | Text |
Enter the insured person’s policy group number or FECA number as shown on the insurance information.
|
| Insured Date of Birth (Month) | Date |
Two-digit birth month of the INSURED, that is the policyholder named in Item 4, not of the patient. Leave blank when the insured's date of birth is not stated in the source.
Example: 03
|
| Insured Date of Birth (Day) | Date |
Two-digit birth day of the INSURED, that is the policyholder named in Item 4, not of the patient. Leave blank when the insured's date of birth is not stated in the source.
Example: 14
|
| Insured Date of Birth (Year) | Date |
Two-digit birth year of the INSURED, that is the policyholder named in Item 4, not of the patient. Leave blank when the insured's date of birth is not stated in the source.
Example: 71
|
| Insured Sex: Male | Checkbox |
Check only when the INSURED, the policyholder named in Item 4, is male. This is the insured's sex, not the patient's - never copy the patient's sex from Item 3.
|
| Insured Sex: Female | Checkbox |
Check only when the INSURED, the policyholder named in Item 4, is female. This is the insured's sex, not the patient's - never copy the patient's sex from Item 3.
|
| Item 24 - Service Line 1 | ||
| Row 1 - 24A Date of Service From (MM) | Text |
Two-digit month on which the service on this line began. Enter the month only, never the whole date. Leave blank if service line 1 is not used.
Example: 07
|
| Row 1 - 24A Date of Service From (DD) | Text |
Two-digit day on which the service on this line began. Enter the day only, never the whole date. Leave blank if service line 1 is not used.
Example: 09
|
| Row 1 - 24A Date of Service From (YY) | Text |
Two-digit year in which the service on this line began, last two digits only (26 for 2026). Never enter the whole date or a four-digit year. Leave blank if service line 1 is not used.
Example: 26
|
| Row 1 - 24A Date of Service To (MM) | Text |
Two-digit month on which the service on this line ended. Repeat the From month for a single-day service. Leave blank if service line 1 is not used.
Example: 07
|
| Row 1 - 24A Date of Service To (DD) | Text |
Two-digit day on which the service on this line ended. Repeat the From day for a single-day service. Leave blank if service line 1 is not used.
Example: 09
|
| Row 1 - 24A Date of Service To (YY) | Text |
Two-digit year in which the service on this line ended, last two digits only (26 for 2026). Repeat the From year for a single-day service. Leave blank if service line 1 is not used.
Example: 26
|
| Row 1 - 24B Place of Service | Text |
Two-digit Place of Service code, keeping any leading zero (11 office, 21 inpatient hospital, 02 telehealth). Leave blank if service line 1 is not used.
Example: 11
|
| Row 1 - 24C Emergency Indicator (EMG) | Text |
Enter Y only when the service was an emergency; otherwise leave blank. Leave blank if service line 1 is not used.
Example: Y
|
| Row 1 - 24D Procedure Code (CPT/HCPCS) | Text |
Five-character CPT or HCPCS procedure code billed on this line, without any modifier. Leave blank if service line 1 is not used.
Example: 99214
|
| Row 1 - 24D Modifier 1 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 1st modifier. Leave blank if service line 1 is not used.
Example: 25
|
| Row 1 - 24D Modifier 2 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 2nd modifier. Leave blank if service line 1 is not used.
Example: LT
|
| Row 1 - 24D Modifier 3 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 3rd modifier. Leave blank if service line 1 is not used.
Example: LT
|
| Row 1 - 24D Modifier 4 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 4th modifier. Leave blank if service line 1 is not used.
Example: LT
|
| Row 1 - 24E Diagnosis Pointer | Text |
Letters identifying which Item 21 diagnosis codes justify the service on this line. Sources usually list these pointers as numbers referring to the Item 21 boxes in order - always convert them to letters: 1 becomes A, 2 becomes B, 3 becomes C, and so on up to 12 becomes L. So a source reading "1, 2" is written AB here, and "1, 3" is written AC. Write the letters together in order, with no commas, spaces or digits. Every service line that has a procedure code must have a pointer - never leave this blank while the rest of the line is filled. Leave blank only if service line 1 is not used.
Example: A
|
| Row 1 - 24F Charges (Dollars) | Text |
Dollar portion of the charge for this line only, digits only, with no dollar sign, comma or decimal point. For $185.30 enter 185 here and 30 in the cents box. Leave blank if service line 1 is not used.
Example: 185
|
| Row 1 - 24F Charges (Cents) | Text |
Two-digit cents portion of the charge for this line. For $185.00 enter 00, for $185.30 enter 30. Never put the dollar amount or the number of units here. Leave blank if service line 1 is not used.
Example: 00
|
| Row 1 - 24G Days or Units | Text |
Number of days or units billed on this line, usually 1. This is a count, not a money amount. Leave blank if service line 1 is not used.
Example: 1
|
| Row 1 - 24H EPSDT / Family Plan | Text |
EPSDT or Family Planning indicator, normally blank. Enter Y only when the service is an EPSDT or family planning service. Leave blank if service line 1 is not used.
Example: Y
|
| Row 1 - 24I Rendering Provider ID Qualifier | Text |
Two-character qualifier describing the non-NPI ID written in the shaded part of box 24J (0B, 1G, G2, LU, ZZ). Leave blank when only an NPI is reported. Never put an NPI or any number here. Leave blank if service line 1 is not used.
Example: ZZ
|
| Row 1 - 24J Rendering Provider Non-NPI ID (shaded) | Text |
Shaded upper half of box 24J: the rendering provider's non-NPI or legacy ID matching the 24I qualifier. Leave blank when only an NPI is reported - the NPI belongs in the unshaded box below, not here. Leave blank if service line 1 is not used.
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| Row 1 - 24J Rendering Provider NPI | Text |
Unshaded lower half of box 24J: the rendering provider's ten-digit NPI, digits only, with no spaces, dashes or thousands separators. Leave blank if service line 1 is not used.
Example: 1548903726
|
| Item 24 - Service Line 2 | ||
| Row 2 - 24A Date of Service From (MM) | Text |
Two-digit month on which the service on this line began. Enter the month only, never the whole date. Leave blank if service line 2 is not used.
Example: 07
|
| Row 2 - 24A Date of Service From (DD) | Text |
Two-digit day on which the service on this line began. Enter the day only, never the whole date. Leave blank if service line 2 is not used.
Example: 09
|
| Row 2 - 24A Date of Service From (YY) | Text |
Two-digit year in which the service on this line began, last two digits only (26 for 2026). Never enter the whole date or a four-digit year. Leave blank if service line 2 is not used.
Example: 26
|
| Row 2 - 24A Date of Service To (MM) | Text |
Two-digit month on which the service on this line ended. Repeat the From month for a single-day service. Leave blank if service line 2 is not used.
Example: 07
|
| Row 2 - 24A Date of Service To (DD) | Text |
Two-digit day on which the service on this line ended. Repeat the From day for a single-day service. Leave blank if service line 2 is not used.
Example: 09
|
| Row 2 - 24A Date of Service To (YY) | Text |
Two-digit year in which the service on this line ended, last two digits only (26 for 2026). Repeat the From year for a single-day service. Leave blank if service line 2 is not used.
Example: 26
|
| Row 2 - 24B Place of Service | Text |
Two-digit Place of Service code, keeping any leading zero (11 office, 21 inpatient hospital, 02 telehealth). Leave blank if service line 2 is not used.
Example: 11
|
| Row 2 - 24C Emergency Indicator (EMG) | Text |
Enter Y only when the service was an emergency; otherwise leave blank. Leave blank if service line 2 is not used.
Example: Y
|
| Row 2 - 24D Procedure Code (CPT/HCPCS) | Text |
Five-character CPT or HCPCS procedure code billed on this line, without any modifier. Leave blank if service line 2 is not used.
Example: 99214
|
| Row 2 - 24D Modifier 1 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 1st modifier. Leave blank if service line 2 is not used.
Example: 25
|
| Row 2 - 24D Modifier 2 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 2nd modifier. Leave blank if service line 2 is not used.
Example: LT
|
| Row 2 - 24D Modifier 3 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 3rd modifier. Leave blank if service line 2 is not used.
Example: LT
|
| Row 2 - 24D Modifier 4 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 4th modifier. Leave blank if service line 2 is not used.
Example: LT
|
| Row 2 - 24E Diagnosis Pointer | Text |
Letters identifying which Item 21 diagnosis codes justify the service on this line. Sources usually list these pointers as numbers referring to the Item 21 boxes in order - always convert them to letters: 1 becomes A, 2 becomes B, 3 becomes C, and so on up to 12 becomes L. So a source reading "1, 2" is written AB here, and "1, 3" is written AC. Write the letters together in order, with no commas, spaces or digits. Every service line that has a procedure code must have a pointer - never leave this blank while the rest of the line is filled. Leave blank only if service line 2 is not used.
Example: A
|
| Row 2 - 24F Charges (Dollars) | Text |
Dollar portion of the charge for this line only, digits only, with no dollar sign, comma or decimal point. For $185.30 enter 185 here and 30 in the cents box. Leave blank if service line 2 is not used.
Example: 185
|
| Row 2 - 24F Charges (Cents) | Text |
Two-digit cents portion of the charge for this line. For $185.00 enter 00, for $185.30 enter 30. Never put the dollar amount or the number of units here. Leave blank if service line 2 is not used.
Example: 00
|
| Row 2 - 24G Days or Units | Text |
Number of days or units billed on this line, usually 1. This is a count, not a money amount. Leave blank if service line 2 is not used.
Example: 1
|
| Row 2 - 24H EPSDT / Family Plan | Text |
EPSDT or Family Planning indicator, normally blank. Enter Y only when the service is an EPSDT or family planning service. Leave blank if service line 2 is not used.
Example: Y
|
| Row 2 - 24I Rendering Provider ID Qualifier | Text |
Two-character qualifier describing the non-NPI ID written in the shaded part of box 24J (0B, 1G, G2, LU, ZZ). Leave blank when only an NPI is reported. Never put an NPI or any number here. Leave blank if service line 2 is not used.
Example: ZZ
|
| Row 2 - 24J Rendering Provider Non-NPI ID (shaded) | Text |
Shaded upper half of box 24J: the rendering provider's non-NPI or legacy ID matching the 24I qualifier. Leave blank when only an NPI is reported - the NPI belongs in the unshaded box below, not here. Leave blank if service line 2 is not used.
|
| Row 2 - 24J Rendering Provider NPI | Text |
Unshaded lower half of box 24J: the rendering provider's ten-digit NPI, digits only, with no spaces, dashes or thousands separators. Leave blank if service line 2 is not used.
Example: 1548903726
|
| Item 24 - Service Line 3 | ||
| Row 3 - 24A Date of Service From (MM) | Text |
Two-digit month on which the service on this line began. Enter the month only, never the whole date. Leave blank if service line 3 is not used.
Example: 07
|
| Row 3 - 24A Date of Service From (DD) | Text |
Two-digit day on which the service on this line began. Enter the day only, never the whole date. Leave blank if service line 3 is not used.
Example: 09
|
| Row 3 - 24A Date of Service From (YY) | Text |
Two-digit year in which the service on this line began, last two digits only (26 for 2026). Never enter the whole date or a four-digit year. Leave blank if service line 3 is not used.
Example: 26
|
| Row 3 - 24A Date of Service To (MM) | Text |
Two-digit month on which the service on this line ended. Repeat the From month for a single-day service. Leave blank if service line 3 is not used.
Example: 07
|
| Row 3 - 24A Date of Service To (DD) | Text |
Two-digit day on which the service on this line ended. Repeat the From day for a single-day service. Leave blank if service line 3 is not used.
Example: 09
|
| Row 3 - 24A Date of Service To (YY) | Text |
Two-digit year in which the service on this line ended, last two digits only (26 for 2026). Repeat the From year for a single-day service. Leave blank if service line 3 is not used.
Example: 26
|
| Row 3 - 24B Place of Service | Text |
Two-digit Place of Service code, keeping any leading zero (11 office, 21 inpatient hospital, 02 telehealth). Leave blank if service line 3 is not used.
Example: 11
|
| Row 3 - 24C Emergency Indicator (EMG) | Text |
Enter Y only when the service was an emergency; otherwise leave blank. Leave blank if service line 3 is not used.
Example: Y
|
| Row 3 - 24D Procedure Code (CPT/HCPCS) | Text |
Five-character CPT or HCPCS procedure code billed on this line, without any modifier. Leave blank if service line 3 is not used.
Example: 99214
|
| Row 3 - 24D Modifier 1 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 1st modifier. Leave blank if service line 3 is not used.
Example: 25
|
| Row 3 - 24D Modifier 2 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 2nd modifier. Leave blank if service line 3 is not used.
Example: LT
|
| Row 3 - 24D Modifier 3 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 3rd modifier. Leave blank if service line 3 is not used.
Example: LT
|
| Row 3 - 24D Modifier 4 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 4th modifier. Leave blank if service line 3 is not used.
Example: LT
|
| Row 3 - 24E Diagnosis Pointer | Text |
Letters identifying which Item 21 diagnosis codes justify the service on this line. Sources usually list these pointers as numbers referring to the Item 21 boxes in order - always convert them to letters: 1 becomes A, 2 becomes B, 3 becomes C, and so on up to 12 becomes L. So a source reading "1, 2" is written AB here, and "1, 3" is written AC. Write the letters together in order, with no commas, spaces or digits. Every service line that has a procedure code must have a pointer - never leave this blank while the rest of the line is filled. Leave blank only if service line 3 is not used.
Example: A
|
| Row 3 - 24F Charges (Dollars) | Text |
Dollar portion of the charge for this line only, digits only, with no dollar sign, comma or decimal point. For $185.30 enter 185 here and 30 in the cents box. Leave blank if service line 3 is not used.
Example: 185
|
| Row 3 - 24F Charges (Cents) | Text |
Two-digit cents portion of the charge for this line. For $185.00 enter 00, for $185.30 enter 30. Never put the dollar amount or the number of units here. Leave blank if service line 3 is not used.
Example: 00
|
| Row 3 - 24G Days or Units | Text |
Number of days or units billed on this line, usually 1. This is a count, not a money amount. Leave blank if service line 3 is not used.
Example: 1
|
| Row 3 - 24H EPSDT / Family Plan | Text |
EPSDT or Family Planning indicator, normally blank. Enter Y only when the service is an EPSDT or family planning service. Leave blank if service line 3 is not used.
Example: Y
|
| Row 3 - 24I Rendering Provider ID Qualifier | Text |
Two-character qualifier describing the non-NPI ID written in the shaded part of box 24J (0B, 1G, G2, LU, ZZ). Leave blank when only an NPI is reported. Never put an NPI or any number here. Leave blank if service line 3 is not used.
Example: ZZ
|
| Row 3 - 24J Rendering Provider Non-NPI ID (shaded) | Text |
Shaded upper half of box 24J: the rendering provider's non-NPI or legacy ID matching the 24I qualifier. Leave blank when only an NPI is reported - the NPI belongs in the unshaded box below, not here. Leave blank if service line 3 is not used.
|
| Row 3 - 24J Rendering Provider NPI | Text |
Unshaded lower half of box 24J: the rendering provider's ten-digit NPI, digits only, with no spaces, dashes or thousands separators. Leave blank if service line 3 is not used.
Example: 1548903726
|
| Item 24 - Service Line 4 | ||
| Row 4 - 24A Date of Service From (MM) | Text |
Two-digit month on which the service on this line began. Enter the month only, never the whole date. Leave blank if service line 4 is not used.
Example: 07
|
| Row 4 - 24A Date of Service From (DD) | Text |
Two-digit day on which the service on this line began. Enter the day only, never the whole date. Leave blank if service line 4 is not used.
Example: 09
|
| Row 4 - 24A Date of Service From (YY) | Text |
Two-digit year in which the service on this line began, last two digits only (26 for 2026). Never enter the whole date or a four-digit year. Leave blank if service line 4 is not used.
Example: 26
|
| Row 4 - 24A Date of Service To (MM) | Text |
Two-digit month on which the service on this line ended. Repeat the From month for a single-day service. Leave blank if service line 4 is not used.
Example: 07
|
| Row 4 - 24A Date of Service To (DD) | Text |
Two-digit day on which the service on this line ended. Repeat the From day for a single-day service. Leave blank if service line 4 is not used.
Example: 09
|
| Row 4 - 24A Date of Service To (YY) | Text |
Two-digit year in which the service on this line ended, last two digits only (26 for 2026). Repeat the From year for a single-day service. Leave blank if service line 4 is not used.
Example: 26
|
| Row 4 - 24B Place of Service | Text |
Two-digit Place of Service code, keeping any leading zero (11 office, 21 inpatient hospital, 02 telehealth). Leave blank if service line 4 is not used.
Example: 11
|
| Row 4 - 24C Emergency Indicator (EMG) | Text |
Enter Y only when the service was an emergency; otherwise leave blank. Leave blank if service line 4 is not used.
Example: Y
|
| Row 4 - 24D Procedure Code (CPT/HCPCS) | Text |
Five-character CPT or HCPCS procedure code billed on this line, without any modifier. Leave blank if service line 4 is not used.
Example: 99214
|
| Row 4 - 24D Modifier 1 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 1st modifier. Leave blank if service line 4 is not used.
Example: 25
|
| Row 4 - 24D Modifier 2 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 2nd modifier. Leave blank if service line 4 is not used.
Example: LT
|
| Row 4 - 24D Modifier 3 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 3rd modifier. Leave blank if service line 4 is not used.
Example: LT
|
| Row 4 - 24D Modifier 4 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 4th modifier. Leave blank if service line 4 is not used.
Example: LT
|
| Row 4 - 24E Diagnosis Pointer | Text |
Letters identifying which Item 21 diagnosis codes justify the service on this line. Sources usually list these pointers as numbers referring to the Item 21 boxes in order - always convert them to letters: 1 becomes A, 2 becomes B, 3 becomes C, and so on up to 12 becomes L. So a source reading "1, 2" is written AB here, and "1, 3" is written AC. Write the letters together in order, with no commas, spaces or digits. Every service line that has a procedure code must have a pointer - never leave this blank while the rest of the line is filled. Leave blank only if service line 4 is not used.
Example: A
|
| Row 4 - 24F Charges (Dollars) | Text |
Dollar portion of the charge for this line only, digits only, with no dollar sign, comma or decimal point. For $185.30 enter 185 here and 30 in the cents box. Leave blank if service line 4 is not used.
Example: 185
|
| Row 4 - 24F Charges (Cents) | Text |
Two-digit cents portion of the charge for this line. For $185.00 enter 00, for $185.30 enter 30. Never put the dollar amount or the number of units here. Leave blank if service line 4 is not used.
Example: 00
|
| Row 4 - 24G Days or Units | Text |
Number of days or units billed on this line, usually 1. This is a count, not a money amount. Leave blank if service line 4 is not used.
Example: 1
|
| Row 4 - 24H EPSDT / Family Plan | Text |
EPSDT or Family Planning indicator, normally blank. Enter Y only when the service is an EPSDT or family planning service. Leave blank if service line 4 is not used.
Example: Y
|
| Row 4 - 24I Rendering Provider ID Qualifier | Text |
Two-character qualifier describing the non-NPI ID written in the shaded part of box 24J (0B, 1G, G2, LU, ZZ). Leave blank when only an NPI is reported. Never put an NPI or any number here. Leave blank if service line 4 is not used.
Example: ZZ
|
| Row 4 - 24J Rendering Provider Non-NPI ID (shaded) | Text |
Shaded upper half of box 24J: the rendering provider's non-NPI or legacy ID matching the 24I qualifier. Leave blank when only an NPI is reported - the NPI belongs in the unshaded box below, not here. Leave blank if service line 4 is not used.
|
| Row 4 - 24J Rendering Provider NPI | Text |
Unshaded lower half of box 24J: the rendering provider's ten-digit NPI, digits only, with no spaces, dashes or thousands separators. Leave blank if service line 4 is not used.
Example: 1548903726
|
| Item 24 - Service Line 5 | ||
| Row 5 - 24A Date of Service From (MM) | Text |
Two-digit month on which the service on this line began. Enter the month only, never the whole date. Leave blank if service line 5 is not used.
Example: 07
|
| Row 5 - 24A Date of Service From (DD) | Text |
Two-digit day on which the service on this line began. Enter the day only, never the whole date. Leave blank if service line 5 is not used.
Example: 09
|
| Row 5 - 24A Date of Service From (YY) | Text |
Two-digit year in which the service on this line began, last two digits only (26 for 2026). Never enter the whole date or a four-digit year. Leave blank if service line 5 is not used.
Example: 26
|
| Row 5 - 24A Date of Service To (MM) | Text |
Two-digit month on which the service on this line ended. Repeat the From month for a single-day service. Leave blank if service line 5 is not used.
Example: 07
|
| Row 5 - 24A Date of Service To (DD) | Text |
Two-digit day on which the service on this line ended. Repeat the From day for a single-day service. Leave blank if service line 5 is not used.
Example: 09
|
| Row 5 - 24A Date of Service To (YY) | Text |
Two-digit year in which the service on this line ended, last two digits only (26 for 2026). Repeat the From year for a single-day service. Leave blank if service line 5 is not used.
Example: 26
|
| Row 5 - 24B Place of Service | Text |
Two-digit Place of Service code, keeping any leading zero (11 office, 21 inpatient hospital, 02 telehealth). Leave blank if service line 5 is not used.
Example: 11
|
| Row 5 - 24C Emergency Indicator (EMG) | Text |
Enter Y only when the service was an emergency; otherwise leave blank. Leave blank if service line 5 is not used.
Example: Y
|
| Row 5 - 24D Procedure Code (CPT/HCPCS) | Text |
Five-character CPT or HCPCS procedure code billed on this line, without any modifier. Leave blank if service line 5 is not used.
Example: 99214
|
| Row 5 - 24D Modifier 1 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 1st modifier. Leave blank if service line 5 is not used.
Example: 25
|
| Row 5 - 24D Modifier 2 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 2nd modifier. Leave blank if service line 5 is not used.
Example: LT
|
| Row 5 - 24D Modifier 3 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 3rd modifier. Leave blank if service line 5 is not used.
Example: LT
|
| Row 5 - 24D Modifier 4 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 4th modifier. Leave blank if service line 5 is not used.
Example: LT
|
| Row 5 - 24E Diagnosis Pointer | Text |
Letters identifying which Item 21 diagnosis codes justify the service on this line. Sources usually list these pointers as numbers referring to the Item 21 boxes in order - always convert them to letters: 1 becomes A, 2 becomes B, 3 becomes C, and so on up to 12 becomes L. So a source reading "1, 2" is written AB here, and "1, 3" is written AC. Write the letters together in order, with no commas, spaces or digits. Every service line that has a procedure code must have a pointer - never leave this blank while the rest of the line is filled. Leave blank only if service line 5 is not used.
Example: A
|
| Row 5 - 24F Charges (Dollars) | Text |
Dollar portion of the charge for this line only, digits only, with no dollar sign, comma or decimal point. For $185.30 enter 185 here and 30 in the cents box. Leave blank if service line 5 is not used.
Example: 185
|
| Row 5 - 24F Charges (Cents) | Text |
Two-digit cents portion of the charge for this line. For $185.00 enter 00, for $185.30 enter 30. Never put the dollar amount or the number of units here. Leave blank if service line 5 is not used.
Example: 00
|
| Row 5 - 24G Days or Units | Text |
Number of days or units billed on this line, usually 1. This is a count, not a money amount. Leave blank if service line 5 is not used.
Example: 1
|
| Row 5 - 24H EPSDT / Family Plan | Text |
EPSDT or Family Planning indicator, normally blank. Enter Y only when the service is an EPSDT or family planning service. Leave blank if service line 5 is not used.
Example: Y
|
| Row 5 - 24I Rendering Provider ID Qualifier | Text |
Two-character qualifier describing the non-NPI ID written in the shaded part of box 24J (0B, 1G, G2, LU, ZZ). Leave blank when only an NPI is reported. Never put an NPI or any number here. Leave blank if service line 5 is not used.
Example: ZZ
|
| Row 5 - 24J Rendering Provider Non-NPI ID (shaded) | Text |
Shaded upper half of box 24J: the rendering provider's non-NPI or legacy ID matching the 24I qualifier. Leave blank when only an NPI is reported - the NPI belongs in the unshaded box below, not here. Leave blank if service line 5 is not used.
|
| Row 5 - 24J Rendering Provider NPI | Text |
Unshaded lower half of box 24J: the rendering provider's ten-digit NPI, digits only, with no spaces, dashes or thousands separators. Leave blank if service line 5 is not used.
Example: 1548903726
|
| Item 24 - Service Line 6 | ||
| Row 6 - 24A Date of Service From (MM) | Text |
Two-digit month on which the service on this line began. Enter the month only, never the whole date. Leave blank if service line 6 is not used.
Example: 07
|
| Row 6 - 24A Date of Service From (DD) | Text |
Two-digit day on which the service on this line began. Enter the day only, never the whole date. Leave blank if service line 6 is not used.
Example: 09
|
| Row 6 - 24A Date of Service From (YY) | Text |
Two-digit year in which the service on this line began, last two digits only (26 for 2026). Never enter the whole date or a four-digit year. Leave blank if service line 6 is not used.
Example: 26
|
| Row 6 - 24A Date of Service To (MM) | Text |
Two-digit month on which the service on this line ended. Repeat the From month for a single-day service. Leave blank if service line 6 is not used.
Example: 07
|
| Row 6 - 24A Date of Service To (DD) | Text |
Two-digit day on which the service on this line ended. Repeat the From day for a single-day service. Leave blank if service line 6 is not used.
Example: 09
|
| Row 6 - 24A Date of Service To (YY) | Text |
Two-digit year in which the service on this line ended, last two digits only (26 for 2026). Repeat the From year for a single-day service. Leave blank if service line 6 is not used.
Example: 26
|
| Row 6 - 24B Place of Service | Text |
Two-digit Place of Service code, keeping any leading zero (11 office, 21 inpatient hospital, 02 telehealth). Leave blank if service line 6 is not used.
Example: 11
|
| Row 6 - 24C Emergency Indicator (EMG) | Text |
Enter Y only when the service was an emergency; otherwise leave blank. Leave blank if service line 6 is not used.
Example: Y
|
| Row 6 - 24D Procedure Code (CPT/HCPCS) | Text |
Five-character CPT or HCPCS procedure code billed on this line, without any modifier. Leave blank if service line 6 is not used.
Example: 99214
|
| Row 6 - 24D Modifier 1 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 1st modifier. Leave blank if service line 6 is not used.
Example: 25
|
| Row 6 - 24D Modifier 2 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 2nd modifier. Leave blank if service line 6 is not used.
Example: LT
|
| Row 6 - 24D Modifier 3 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 3rd modifier. Leave blank if service line 6 is not used.
Example: LT
|
| Row 6 - 24D Modifier 4 | Text |
Two-character CPT/HCPCS modifier, which may contain letters (25, 59, LT, RT, GP). Leave blank when this line has no 4th modifier. Leave blank if service line 6 is not used.
Example: LT
|
| Row 6 - 24E Diagnosis Pointer | Text |
Letters identifying which Item 21 diagnosis codes justify the service on this line. Sources usually list these pointers as numbers referring to the Item 21 boxes in order - always convert them to letters: 1 becomes A, 2 becomes B, 3 becomes C, and so on up to 12 becomes L. So a source reading "1, 2" is written AB here, and "1, 3" is written AC. Write the letters together in order, with no commas, spaces or digits. Every service line that has a procedure code must have a pointer - never leave this blank while the rest of the line is filled. Leave blank only if service line 6 is not used.
Example: A
|
| Row 6 - 24F Charges (Dollars) | Text |
Dollar portion of the charge for this line only, digits only, with no dollar sign, comma or decimal point. For $185.30 enter 185 here and 30 in the cents box. Leave blank if service line 6 is not used.
Example: 185
|
| Row 6 - 24F Charges (Cents) | Text |
Two-digit cents portion of the charge for this line. For $185.00 enter 00, for $185.30 enter 30. Never put the dollar amount or the number of units here. Leave blank if service line 6 is not used.
Example: 00
|
| Row 6 - 24G Days or Units | Text |
Number of days or units billed on this line, usually 1. This is a count, not a money amount. Leave blank if service line 6 is not used.
Example: 1
|
| Row 6 - 24H EPSDT / Family Plan | Text |
EPSDT or Family Planning indicator, normally blank. Enter Y only when the service is an EPSDT or family planning service. Leave blank if service line 6 is not used.
Example: Y
|
| Row 6 - 24I Rendering Provider ID Qualifier | Text |
Two-character qualifier describing the non-NPI ID written in the shaded part of box 24J (0B, 1G, G2, LU, ZZ). Leave blank when only an NPI is reported. Never put an NPI or any number here. Leave blank if service line 6 is not used.
Example: ZZ
|
| Row 6 - 24J Rendering Provider Non-NPI ID (shaded) | Text |
Shaded upper half of box 24J: the rendering provider's non-NPI or legacy ID matching the 24I qualifier. Leave blank when only an NPI is reported - the NPI belongs in the unshaded box below, not here. Leave blank if service line 6 is not used.
|
| Row 6 - 24J Rendering Provider NPI | Text |
Unshaded lower half of box 24J: the rendering provider's ten-digit NPI, digits only, with no spaces, dashes or thousands separators. Leave blank if service line 6 is not used.
Example: 1548903726
|
| Other Claim ID & Plan Name | ||
| Other Claim ID Qualifier | Text |
Enter the qualifier code that identifies the type/source of the other claim ID.
|
| Other Claim ID | Text |
Enter the other claim identification number associated with the patient’s coverage.
|
| Other Insurance Plan Name | Text |
Enter the name of the other insurance plan or program related to the other claim.
|
| Other Insured Information | ||
| Other Insured Name | Text |
Enter the other insured person’s full name (last name, first name, middle initial) as it appears on their insurance card. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Insured Policy/Group Number | Text |
Enter the policy number or group number for the other insured person’s health plan. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Reserved for NUCC Use (9b) | Text |
Enter the value requested for this reserved NUCC field, if instructed to do so by the payer. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Reserved for NUCC Use (9c) | Text |
Enter the value requested for this reserved NUCC field, if instructed to do so by the payer. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Insurance Plan/Program Name | Text |
Enter the name of the other insured person’s insurance plan or program. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Patient & Insured Basic Info | ||
| Insured ID Number | Text |
Enter the insured person’s identification number exactly as shown on the insurance card. Fill only if 'Medicare', 'Medicaid', 'TRICARE', 'CHAMPVA', 'Group Health Plan', 'FECA / Black Lung', 'Other' is 'Yes' (any).
Depends on:
Medicare, Medicaid, TRICARE, CHAMPVA, Group Health Plan, FECA / Black Lung, Other
|
| Patient Name | Text |
Enter the patient’s full name (last name, first name, and middle initial).
|
| Patient Birth Month | Date |
Enter the month of the patient’s date of birth.
|
| Patient Birth Day | Date |
Enter the day of the month of the patient’s date of birth.
|
| Patient Birth Year | Date |
Enter the year of the patient’s date of birth.
|
| Sex: Male | Checkbox |
Check this box if the patient is male.
|
| Sex: Female | Checkbox |
Check this box if the patient is female.
|
| Insured Name | Text |
Enter the insured person’s full name (last name, first name, and middle initial).
|
| Patient Address & Phone | ||
| Patient Street Address | Text |
Enter the patient's street address (house/building number and street name).
|
| Patient City | Text |
Enter the city where the patient lives.
|
| Patient State | Text |
Enter the state where the patient lives.
|
| Patient ZIP Code | Text |
Enter the patient's ZIP or postal code.
|
| Patient Telephone (Area Code) | Text |
Enter the area code for the patient's telephone number.
|
| Patient Telephone Number | Text |
Enter the patient's telephone number.
|
| Patient Condition Related To (Employment/Accidents) | ||
| Employment? (Current or Previous) — Yes | Checkbox |
Check this box if the patient’s condition is related to current or previous employment.
|
| Employment? (Current or Previous) — No | Checkbox |
Check this box if the patient’s condition is not related to current or previous employment.
|
| Auto Accident? — Yes | Checkbox |
Check this box if the patient’s condition is related to an automobile accident.
|
| Auto Accident? — No | Checkbox |
Check this box if the patient’s condition is not related to an automobile accident.
|
| Auto Accident Location (State) | Text |
Enter the U.S. state where the auto accident occurred, if the patient’s condition is related to an auto accident. Fill only if 'Auto Accident? — Yes' is 'Yes'.
Depends on:
Auto Accident? — Yes
|
| Other Accident? — Yes | Checkbox |
Check this box if the patient’s condition is related to an accident other than an auto accident.
|
| Other Accident? — No | Checkbox |
Check this box if the patient’s condition is not related to any accident other than an auto accident.
|
| Patient Relationship to Insured | ||
| Self | Checkbox |
Check this box if the patient is the insured person (the policyholder).
|
| Spouse | Checkbox |
Check this box if the patient is the insured person’s spouse.
|
| Child | Checkbox |
Check this box if the patient is the insured person’s child (dependent).
|
| Other | Checkbox |
Check this box if the patient’s relationship to the insured is not self, spouse, or child.
|
| Patient/Insured Signatures & Dates | ||
| Patient/Authorized Person Signature | Text |
Enter the signature of the patient or the authorized person who is signing to authorize release of information and payment of benefits.
|
| Signature Date (Patient/Authorized Person) | Text |
Date on which the patient or authorized person signed, written in MM/DD/YYYY format with a two-digit month, a two-digit day and a FULL four-digit year. Expand any abbreviated date found in the source: 7/9/26 must be written as 07/09/2026. Never drop the day and never shorten the year.
Example: 07/09/2026
|
| Insured/Authorized Person Signature | Text |
Enter the signature of the insured or authorized person authorizing payment of medical benefits to the provider or supplier.
|
| Physician/Supplier Signature (Item 31) | ||
| Physician/Supplier Signature | Text |
Enter the signature of the physician or supplier (including degrees or credentials) certifying the claim.
|
| Signature Date (Physician/Supplier) | Text |
Date on which the physician or supplier signed, written in MM/DD/YYYY format with a two-digit month, a two-digit day and a FULL four-digit year. Expand any abbreviated date found in the source: 7/9/26 must be written as 07/09/2026. Never drop the day and never shorten the year.
Example: 07/09/2026
|
| Prior Authorization Number (Item 23) | ||
| Prior Authorization Number | Text |
Enter the prior authorization number issued for the services being claimed (Item 23).
|
| Referring Provider Information (Item 17) | ||
| Referring provider last name | Text |
Enter the referring provider’s last name.
|
| Referring provider first name | Text |
Enter the referring provider’s first name (and middle initial if applicable).
|
| Referring provider ID qualifier (17a) | Text |
Enter the qualifier that identifies the type of non-NPI referring provider ID reported in Item 17a.
|
| Referring provider ID number (17a) | Text |
Enter the referring provider’s non-NPI identification number corresponding to the qualifier in Item 17a.
|
| Referring provider NPI (17b) | Text |
Ten-digit NPI of the referring provider named in Item 17, digits only, with no spaces, dashes or thousands separators.
Example: 1093827465
|
| Reserved for NUCC Use (Item 8) | ||
| NUCC Use (Item 8) | Text |
Enter any code or information provided by NUCC for Item 8, if applicable; otherwise leave blank.
|
| Resubmission & Original Reference (Item 22) | ||
| Resubmission Code | Text |
Enter the code that indicates this claim is a resubmission or corrected/replacement claim, if applicable.
|
| Original Reference Number | Text |
Enter the reference number or identifier for the original claim being resubmitted or corrected.
|
| Service Facility Location (Item 32) | ||
| Service Facility Name and Address | Text |
Enter the name and full address of the facility where the services were provided (street, city, state, and ZIP code).
|
| Service Facility NPI | Text |
Enter the National Provider Identifier (NPI) for the service facility.
|
| Service Facility Other ID | Text |
Enter any additional identification number for the service facility (if applicable).
|
| Tax ID, Patient Account & Claim Totals (Items 25-30) | ||
| Federal Tax ID Number | Text |
Enter the billing provider’s Federal Tax Identification Number (TIN).
|
| Federal Tax ID Type: SSN | Checkbox |
Check this box if the Federal Tax ID number entered in Item 25 is a Social Security Number (SSN).
|
| Federal Tax ID Type: EIN | Checkbox |
Check this box if the Federal Tax ID number entered in Item 25 is an Employer Identification Number (EIN).
|
| Patient Account Number | Text |
Enter the patient’s account number used by the provider or facility to identify this claim.
|
| Accept Assignment: Yes | Checkbox |
Check this box if the provider accepts assignment of benefits for this claim.
|
| Accept Assignment: No | Checkbox |
Check this box if the provider does not accept assignment of benefits for this claim.
|
| Unable to Work Dates (Item 16) | ||
| Unable to Work From (Month) | Date |
Enter the month when the patient first became unable to work in their current occupation.
|
| Unable to Work From (Day) | Date |
Enter the day of the month when the patient first became unable to work in their current occupation.
|
| Unable to Work From (Year) | Date |
Enter the year when the patient first became unable to work in their current occupation.
|
| Unable to Work To (Month) | Date |
Enter the month when the patient returned to work (or the end month of the period they were unable to work).
|
| Unable to Work To (Day) | Date |
Enter the day of the month when the patient returned to work (or the end day of the period they were unable to work).
|
| Unable to Work To (Year) | Text |
Enter the year when the patient returned to work (or the end year of the period they were unable to work).
|