The HCFA 1500 is a common insurance form used by many health care providers to bill Medicare for patient services and medical supplies. Filling out the form is a two-part process: the patient completes boxes 2 through 13 and blocks 19 through 33 are completed by the health care provider.
Instructions
Patient Section
1. Enter the patient's full name, sex and date of birth in boxes 2 and 3.
2. Enter the insured person's name in box 4 if it is different than the patient. For example, if the insured person is the patient's parent. Enter the patient's address in box 5.
3. Enter the patient's relationship to the insured in box 6. For example: son, daughter or stepchild.
4. Enter the insured person's address in box 7 if it is different than the patient's address.
5. Enter the patient's work status and martial status in box 8.
6. Enter information regarding any other insurance that the patient may have, either from work or Medicare supplemental coverage in box 9. Include the insured person's name, policy number, employer's name and name of the insurance company.
7. Check "Yes" or "No" if the injury is related to a work or auto accident in box 10. If you checked "Yes" to either of these choices, enter the name of the work or auto insurance company that may be liable for coverage in box 11.
8. Enter the patient or authorized person's signature in box 12 to authorize the health care provider to release the patient information to Medicare. Enter the patient or authorized person's signature in box 13 to authorize the Medicare payment.
Health Care Provider Section
9. Enter any additional patient insurance information in block 19 that did not correlate to the information required by the previous boxes.
10. Enter the patient's diagnosis code in block 21. Enter the patient's pre-authorization number in block 23.
11. Enter the date(s) of service and where the service was performed in block 24. Also add the diagnosis code from block 21 and the procedure code. List the procedure charges and date(s) that the specific procedures were performed in block 24 F and G.
12. Enter the health care provider's federal tax number or Social Security number in block 25.
13. Enter the total amount being charged for the services in block 28. Enter the amount that the patient made as a co-payment in block 29. Enter the amount that is being billed to Medicare in block 30.
14. Enter the signature and address of the health care provider in blocks 31 and 32. Enter any additional billing information in block 33.
Tags: Enter patient, block Enter, care provider, health care, insured person, health care provider