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Cms 1500 PDF Filler Form
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Other
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9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
Full-Time
Part-Time
Student
Student
10. IS PATIENT’S CONDITION RELATED TO:
a. OTHER INSURED’S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
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Employed
Married
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b. OTHER INSURED’S DATE OF BIRTH
MM
DD
YY
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b. AUTO ACCIDENT?
SEX
M
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c. EMPLOYER’S NAME OR SCHOOL NAME
YES
F
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PLACE (State)
■ NO
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YES
SIGNED
ZIP CODE
(
)
11. INSURED’S POLICY GROUP...
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People also ask hcfa 1500 form pdf
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What is the difference between CFA 1500 and CMS 1500?
The UB-04 (CMS 1450) is a claim form used by hospitals, nursing facilities, in-patient, and other facility providers. ... On the other hand, the HCFA-1500 (CMS 1500) is a medical claim form employed by individual doctors & practices, nurses, and professionals, including therapists, chiropractors, and out-patient clinics. -
What is the CMS 1450 form used for?
The Form CMS-1450, also known as the UB-04, is the standard claim form to bill Medicare Administrative Contractors (Macs) when a signNow claim is allowed. In addition to billing Medicare, the 837I and Form CMS-1450 may be suitable for billing various government and some private insurers. -
What does CFA form stand for?
Acronym. Definition. CFA. HEvalth Care Financing Administration (now the Centers for Medicare and Medicaid Services) -
What goes in box 17a on CMS 1500?
Box 17a is the non-NPI ID of the referring provider and is a unique identifier or a taxonomy code. The qualifier indicating what the number represents is reported in the qualifier field to the immediate right of 17a. -
What is the difference between CMS 1500 and ub04 claim forms?
The UB-04 (CMS 1450) is a claim form used by hospitals, nursing facilities, in-patient, and other facility providers. ... On the other hand, the HCFA-1500 (CMS 1500) is a medical claim form employed by individual doctors & practices, nurses, and professionals, including therapists, chiropractors, and out-patient clinics.
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