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CMS-1500 Template. BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BY APPLICABLE PROGRAMS. NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under ...
Sep 6, 2023 · The only acceptable claim forms are those printed in Flint OCR Red, J6983, (or exact match) ink. Although a copy of the CMS-1500 form can be downloaded, copies of the form cannot be used for submission of claims, since your copy may not accurately replicate the scale and OCR color of the form.
INSURED’S I.D. NUMBER (For Program in Item 1) 4. INSURED’S NAME (Last Name, First Name, Middle Initial) 7. INSURED’S ADDRESS (No., Street) CITY STATE ZIP CODE TELEPHONE (Include Area Code) 11. INSURED’S POLICY GROUP OR FECA NUMBER a. INSURED’S DATE OF BIRTH SEX MM DD YY M F b. OTHER CLAIM ID (Designated by NUCC) c. INSURANCE PLAN NAME ...
Get the printable CMS-1500 form. Download a blank 1500 claim template or fill it out online & print it. Use our clear instructions for medical facilities & healthcare providers.
Sep 22, 2023 · Professional Paper Claim Form (CMS-1500) How to Submit Claims: Claims may be electronically submitted to a Medicare carrier, Durable Medical Equipment Medicare Administrative Contractor (DMEMAC), or A/B MAC from a provider's office using a computer with software that meets electronic filing requirements as established by the HIPAA claim ...
Apr 9, 2019 · Our government-approved, free fillable CMS 1500 template makes your lives a little bit easier. This CMS 1500 form, fillable and simple to use, is available to anyone who needs it. Our CMS 1500 form PDF downloadable is simple to use and comes as a blank CMS 1500 claim form PDF.
PRINT ONLY ON OFFICIAL CMS 1500 PAPER CLAIM FORMS FOR LASER OR INK-JET PRINTERS. Paper claims submitted to Medicare are electronically read using Optical Character Recognition (OCR) equipment. This scanning technology allows for the data content on the form to be read and transferred into a format for automated processing by Medicare systems.
