How to Fill Out the HCFA 1500 Claim Form

A Health Insurance Claim Form, or HCFA 1500, provides patient information, physician information and billing codes for claim payment by the insurance company. Completing the HCFA 1500 claim form requires knowledge in medical coding. However, the physician's office or service provider can provide the codes and provider information if you are required to complete the form for insurance purposes.

Instructions

• 1

  Complete Box 1a by adding the insured's identification number listed on her insurance card. Place the patient's name in Box 2 along with her date of birth and sex in Box 3.

• 2

  Place the insured's name in Box 4. In Box 5, enter the patient's address. Mark the correct relationship information for the patient in Box 6. Enter the insured's address in Box 7.

• 3

  Enter the patient's marital status in Box 8 by checking the correct option. Box 9 is reserved for other insurance information. Use Box 10 to check the box that gives information regarding the patient's condition, such as if it is employment- or accident-related.

• 4

  Add the insured's policy group number, date of birth, sex, employer name and plan name in Box 11. Also, check the box "yes" if it is another health insurance plan; otherwise, check "no." Read the back of the HCFA 1500 and sign Box 12 if you wish to provide your medical records to those who request them.

• 5

  Enter the phrase "Signature on File" or "SOF" in Box 13. Box 14 requires the date of the illness or when the symptoms first occurred. Complete Boxes 15 and 16 if the patient was treated previously for the same illness.

• 6

  Place the referring physician's name in Box 17. Enter the dates the patient entered and left the hospital, if applicable, in Box 18. Skip Box 19 and check the correct box for lab in Box 20.

• 7

  Enter the diagnosis codes in Box 21. Up to four codes may be entered following the International Classification of Disease (ICD) guide. Only complete Box 22 if the claim is a Medicaid resubmission. Box 23 is reserved for a pre-authorization number if you have one.

• 8

  Complete Box 24 and enter the Current Procedural Terminology (CPT) codes provided by the American Medical Association. Several codes are allowed with at least one diagnosis for each.

• 9

  Enter the physician's tax ID number in Box 25. The patient's account number is required in Box 26. For the physician to be paid by the insurance company, Box 27 must be checked "yes." Box 28 through 30 are the total charges for the CPT codes.

• 10

  Place the physician signature in Box 31 along with the date. Box 32 requires the facility address. Place the billing facility's information in Box 33.