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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.
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.
CLAIM CODES (Designated by NUCC) READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. SIGNED.
The CMS-1500 form is the standard paper claim form used by a non-institutional provider or supplier to bill Medicare carriers and Medicare administrative contractors (MACs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.
Download a printable version of Form HCFA-1500 by clicking the link below or browse more documents and templates provided by the U.S. Department of Health and Human Services - Centers for Disease Control and Prevention.
1 Φεβ 2012 · Medicare claims & public health emergencies; Guide for Medical Technology Companies and Other Interested Parties
APPROVED OMB-0938-1197 FORM 1500 (02-12) 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. ILLNESS, INJURY, or PREGNANCY (LMP) QUAL. 3.
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