HCFA 1500 Form Instructions

When a person required medical attention, physicians filled out a HCFA 1500 claim form for billing to the insurance company. Since December 17, 2007, the HCFA 1500 claim form was replaced with a CMS 1500 claim form due to the Health Insurance Portability and Accountability Act requirements. These requirements consist of a National Provider Identifier number to be present on all billing forms to represent covered health care providers. Although the CMS 1500 form has replaced the HCFA 1500 form, the only differences between the two claim forms consist of adding information fields to accommodate the National Provider Identifier number.

Instructions

• 1

  Fill out the claim form by placing in your name, address information, date of birth and gender. As the patient, or authorized person filling out the form on the patient's behalf, you will not need to complete boxes 1 and 1a at the top. This section is for the medical carrier information. Continue to fill out the form by writing down the insured person's name, the insured person's address information and the patient's relationship to the insured person -- if different.

• 2

  Supply the patient's status and whether their condition was from a work-related accident, auto accident or some other type of accident. Give the insured person's information such as the policy group or FECA number, date of birth, gender, and their employer's name or school name. Write down the insurance plan name and whether the insured person has any other plan benefits.

• 3

  Place in the required information of anyone else supplying insurance for the patient. Include their insurance plan name, employer's name or school name, policy number, date of birth and gender. Finish filling in the form by signing and dating the signature line as either the patient or authorized person. Also have the insured person sign the form. The bottom of the form describing medical information and procedures given to the patient will be completed by the physician.