You should follow the steps below when filling out the CMS 1500 Claim Form:
Fill out sections 1 – 11 with information about the patient and the subscriber on the account. Required boxes in this section are: 1A, 2, 3, 4, 5, 6, 7 and 11D.
Note: On 11D (Is there another health benefit plan?), check the appropriate box. If YES is checked, then fields 9A – 9D must be completed.
Box 12 requires the patient’s or authorized person’s signature.
If you sign or mark Box 13 in any manner, this may prompt payment to be sent to the provider. Only sign Box 13 if you want monies to be sent to the provider. The patient should not sign within Box 13 if the patient is being treated by an out-of-network provider and reimbursement should be sent to the patient.
Note: Do not make any marks in this box if you would like to receive payment.
Boxes 14 – 33 are not required if you have an itemized bill from the provider that shows the following: