Health Insurance CMS 1500 Claim Form Questions and Answers(A+ Solution guide)

Block 1 - enter an x in the Other box if the patient is covered by an individual or family health plan. Or, enter an X in the Group Health Plan box if the patient is covered by a group health plan NOTE: the patient is covered by a group health plan if a group number is printed on the patient's insurance identification card (or a group number is included on case studies) Block 1a - enter the health insurance identification number as it appears on the patient's insurance card. Do not enter hyphens or spaces in the number Block 2 - enter the patient's last name, first name, and middle initial (separated by commas; DOE, JANE, M) Block 3 - enter the patient's birth date as MM DD YYYY (with spaces). enter an X in the appropriate box to indicate the patient's gender. if the patient's gender is unknown, leave blank Block 4 - enter the policyholder's last name, first name, and middle initial (separated by commas; DOE, JANE, M) Block 5 - enter the patient's mailing address and telephone number. enter the street address on line 1, city and state on line 2 and 5 or 9 digit zip code and phone number on line 3 Block 6 - enter an X in the appropriate box to indicate the patient's relationship to the policyholder. if the patient is an unmarried domestic partner, enter an X in the other box Block 7 - enter the policyholder's mailing address and telephone number. enter the street address on line 1, city and state on line 2, 5 or 9 digit zip code and phone number on line 3 Block 8 - leave blankBlock 9, 9a, 9d - completed if the patient has secondary insurance coverage; otherwise leave blank Block 9b-9c - leave blank Block 10a-10c - enter an X in the appropriate boxes to indicate whether the patient's condition is related to employment, an automobile accident, and/or another type of accident. if an X is entered in the YES box for auto accident, enter the two-character state abbreviation of the patient's residence Block 10d - leave blank Block 11 - enter the policyholder's commercial group number if the patient is covered by a group health plan. do not enter hyphens or spaces in the group number. otherwise, leave blank Block 11a - enter the policyholder's birth date as MM DD YYYY (with spaces) enter an X in the appropriate box to indicate the policyholder's gender, if unknown, leave blank Block 11b - Leave blank, reserved for property and casualty or worker's compensation claims Block 11c - enter the name of the policyholder's commercial health insurance plan Block 11d - enter an X in the NO box (if the patient does not have secondary insurance coverage) Block 12 - enter SIGNATURE ON FILE. leave the date field blank (SOF is also acceptable)