Instructions for Completing the HCFA 1500

Patients seeking reimbursement from their insurance providers for medical treatment that should have been covered by the patient’s medicare, medicaid or other health insurance provider must fill out and file form HCFA 1500. In the year 2007, this form was replaced by form CMS 1500. The forms are essentially identical; the new form is designed to encompass a new numbering system. Basically, the patient must provide information in the appropriate blanks on the form.

Items 1-13: Patient and Insured Information

The first 13 boxes on the form ask for patient and insured information. The first box asks the patient to check the appropriate box for his insurance. If the patient is on medicare, the patient must place an “X” in that box. Boxes 2, 3, 5 and 8 are for the patient. Fill in the patient’s name, birth date and address in the appropriate boxes. In Box 8, check whether the patient is married, single, employed or other. Boxes 4, 6 and 7 must be filled in if the patient is on either his spouse’s or employer’s insurance plan. The holder of the insurance plan (the spouse or the employer) is called the “insured.” Provide the insured’s information in the appropriate boxes. Box 9 is reserved for insureds who go by a different name; fill in that box if appropriate. Box 10 asks the patient to describe the cause of his condition; check the appropriate box. Box 11 asks for the insured’s group or contract number. This can be found on the patient’s insurance card. Boxes 12 and 13 require signatures.

Items 14-33: Physician and Health Care Services Information

The second half of HCFA 1500 must be filled out by the patient’s physician or health care provider. Patients must bring HCFA 1500 to their physician or health care provider so they can fill out the appropriate blanks. The information in this section of the form requires specific information about the patient’s condition, including diagnosis coding and the charges for the medical procedures. This is information that can only be accurately reported by the treating physician or health care provider. Patients should not fill out this section of the form by themselves; forms that are not filled out properly may not be processed, and the patient may not receive the correct amount of reimbursement.