Form CMS-1500 (2012)

What is a CMS 1500 Claim Form (2012)

The CMS-1500 Claim Form is a detailed health insurance blank used by various non-institutional providers to bill Medicare, Medicaid, Tricare, and other government carriers. Copies of other papers, such as test results and patients’ documents, are not required.

What do I need the printable CMS 1500 Form for

• This document was designed for use by non-institutional healthcare providers, suppliers, physicians, and ambulance services (in some cases) to obtain reimbursement for the treatment of insured patients.
• The CMS 1500 blank form can be used to file claims with virtually all private or public insurance payers as it is accepted throughout the US.
• Institutional facilities (e.g., hospitals) cannot use this document. Instead, they should complete CMS-1450.

How To Fill Out a CMS 1500 (2012)

1. Select a healthcare plan from the list provided, for instance, Medicare, and fill in the patient’s details: name, address, date of birth, and contact information.
2. Then enter data related to insurance: its number, to whom it is issued, the title of the insurance plan or program, and so on.
3. The patient (or their designee) must sign and agree to processing the specified data and receiving benefits (if any are implied).
4. Now, go to the block that deals with illness or injury information. Indicate the date of the incident, the diagnosis, the prescribed procedures, their volume and cost, the sick leave period, and so on.
5. The healthcare professional who entered the information must sign the CMS Form 1500 PDF.

How to print on CMS 1500

It is best to fill in the CMS 1500 template electronically, for example, using PDFLiner. You can type in all the necessary information and quickly check it for errors. The finished document can be sent online to recipients by email or using a link or printed. Please note that the original template is red, making it suitable for scanning.

NUCC recommends the use of red ink. However, some providers accept black and white copies, so it’s best to check with your payer in advance for print requirements.

Organizations that work with a fillable CMS 1500 Form

• Non-institutional providers and suppliers.