Form · Claims

CMS-1500 form (HCFA 1500 claim form)

What it is, who uses it, and field-by-field help. Publisher: CMS; form maintained by the National Uniform Claim Committee (NUCC). Links checked October 23, 2026.

Quick answer

The CMS-1500, version 02/12 (OMB 0938-1197), is the standard paper claim physicians and other professionals and suppliers send to Medicare and most health plans. The National Uniform Claim Committee (NUCC) maintains it. Most claims go electronically as the 837P; the paper form is for providers allowed to bill on paper.

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At a glance

Form: CMS-1500 (02/12), also called the HCFA 1500
OMB number: 0938-1197
Used for: Professional and supplier claims (electronic version: ASC X12 837P)
Items: 33 numbered items; service lines in item 24 (6 lines)
Instructions: NUCC 1500 instruction manual; Medicare: Claims Processing Manual ch. 26
Get the form: CMS-1500 form (PDF, sample copy)

Who uses it

Physicians, nurse practitioners, therapists, and other professionals billing for their own services
Suppliers such as DME and ambulance suppliers billing Medicare Part B
Billing staff at practices that are allowed to submit paper claims

Patient and insured (items 1 to 13)

1. Insurance type: Check the program: Medicare, Medicaid, TRICARE, CHAMPVA, group health plan, FECA black lung, or other.
1a. Insured's ID number: The member ID from the insurance card. For Medicare, the Medicare Beneficiary Identifier (MBI).
2. Patient's name: Last name, first name, middle initial, exactly as on the card.
3. Patient's birth date and sex: MM DD YY date of birth and sex.
4. Insured's name: The policyholder. Can be the patient or someone else, such as a spouse or parent.
5. Patient's address: Street, city, state, ZIP, and phone.
6. Patient relationship to insured: Self, spouse, child, or other.
7. Insured's address: The policyholder's address when different from the patient's.
9, 9a, 9d. Other insured: A second policy that may also pay: the other insured's name, policy or group number, and plan name.
10a to 10c. Is the condition related to: Employment, an auto accident (with state), or another accident. Payers use this to find another liable payer.
10d. Claim codes: Codes designated by NUCC, used when a payer asks for them.
11 to 11d. Insured's policy group: The insured's group or FECA number, birth date and sex, other claim ID, plan name, and whether another health plan exists.
12. Patient's signature: Authorizes release of the information needed to process the claim. "Signature on file" is common.
13. Insured's signature: Authorizes payment of benefits to the provider (assignment of benefits).

Claim details (items 14 to 23)

14. Date of current illness, injury, or pregnancy: Onset date with a qualifier for which date it is.
15. Other date: Another date related to the condition, with a qualifier.
16. Dates unable to work: From and to dates the patient could not work in their current job.
17, 17b. Referring provider: Name of the referring, ordering, or supervising provider, with a qualifier, and their NPI in 17b.
18. Hospitalization dates: Admission and discharge dates when services relate to an inpatient stay.
19. Additional claim information: Free text a payer asks for, in the format NUCC designates.
20. Outside lab: Yes if a lab outside the billing office did the test, with its charges.
21. Diagnosis codes: Up to 12 ICD-10-CM codes, A through L, with the ICD indicator (0 for ICD-10). Service lines point back to these letters.
22. Resubmission code: For a corrected or voided claim: the payer's frequency code and the original claim reference number.
23. Prior authorization number: The authorization or referral number the payer issued.

Service lines (item 24, up to 6 lines)

24A. Dates of service: From and to dates for each line.
24B. Place of service: The 2-digit CMS place of service code, such as 11 for an office.
24C. EMG: Emergency indicator, when a payer requires it.
24D. Procedures, services, or supplies: The CPT or HCPCS code and up to four modifiers.
24E. Diagnosis pointer: The letter(s) from item 21 that support this line, primary first.
24F. Charges: The charge for the line.
24G. Days or units: Number of days or units.
24H. EPSDT / family plan: Medicaid EPSDT or family planning indicator when it applies.
24I and 24J. Rendering provider ID: The rendering provider's NPI on the unshaded line, and any other ID with its qualifier on the shaded line.

Provider and totals (items 25 to 33)

25. Federal tax ID: The billing provider's SSN or EIN.
26. Patient's account number: Your internal account number, which comes back on the remittance.
27. Accept assignment: Whether the provider accepts assignment.
28 and 29. Total charge and amount paid: Sum of the line charges, and any amount the patient or another payer already paid.
31. Signature of physician or supplier: The rendering provider's signature, or signature on file, and date.
32, 32a. Service facility location: Where the services were provided, with that location's NPI.
33, 33a. Billing provider info: The billing provider's name, address, phone, and NPI.

Questions

Is the CMS-1500 the same as the HCFA 1500?

Yes. HCFA was CMS's former name, and people still call the form the HCFA 1500. The current version is 02/12.

Can I print the CMS-1500 PDF and mail it?

The CMS PDF is a sample copy for reference. For submitting, CMS points to printed forms, listing the U.S. Government Bookstore and NUCC on its CMS-1500 page. Check your payer's paper claim rules, or bill electronically.

What is the difference between the CMS-1500 and the UB-04?

The CMS-1500 is for professional and supplier services. The UB-04 (CMS-1450) is for institutional claims from hospitals, skilled nursing facilities, and other facilities.