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Fill out the CMS-1500 Health Insurance Claim Form online for free. Download the blank form in PDF and Word formats. Save time with easy filling and printing.
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FOR CHAMPUS CLAIMS: PRINCIPLE PURPOSE(S): To evaluate eligibility for medical care provided by civilian sources and to issue payment upon establishment of eligibility and determination that the services/supplies received are authorized by law.
PLEASE PRINT OR TYPEAPPROVED OMB-0938-1197 FORM 1500 (02-12) Title. Health Insurance Claim Form. Created Date. 20140409155227Z.
The 1500 Health Insurance Claim Form (1500 Claim Form) answers the needs of many health care payers. It is the basic paper claim form prescribed by many payers for claims submitted by physicians, other providers, and suppliers, and in some cases, for ambulance services.
The following is the PDF of the revised 1500 form, including the template and grid versions: (The form image may not print to scale. This image of the form should not be used for claims submission.
1 Φεβ 2012 · Medicare claims & public health emergencies; Guide for Medical Technology Companies and Other Interested Parties
