How to Use an HCFA 1500

In the past, HCFA 1500 was the standard form most physicians used to record patient's personal information and the doctor's treatment so the medical staff could bill the patient's insurance company. On December 17, 2007, the HCFA 1500 was replaced with the CMS 1500 form, according to the State of California's Medi-Cal. ( This was due in part by the Health Insurance Portability and Accountability Act (HIPAA), which stated that a national provider identifier (NPI) number should be present on all medical billing forms. The NPI is used by covered health care providers and health plans for financial and administrative transactions, according to the Centers for Medicare and Medicaid Services .

Instructions

• 1

  Fill out the three parts of the CMS 1500 form (formerly the HCFA 1500 form). Complete the top section if you are the insurance carrier, the middle section if you are the patient or the insurer for the patient and the bottom portion if you are the physician or someone providing medical services such as an ambulance driver.

• 2

  Check the appropriate box on line 1 concerning what type of medical provider or plan the patient or insurer has. Place in the insurance provider's number on line 1a.

• 3

  Fill out section two, lines 2 through 13, if you are the patient or someone who has insurance for the patient. Provide the name and address for the patient, gender, date of birth and relationship status to the insured person. Include the patient's telephone number, patient's marital status, employment status and how the patient became injured. Write in the insured person's personal information, the insured person's policy group name, health plan name and employer's name. Indicate if there is another insured person for the patient and provide this person's information as well. Both the patient and the insured person must sign and date the second section.

• 4

  Complete lines 14 through 33 if you are the physician attending to the patient. Fill in the necessary information regarding the patient's current illness, if the patient had this illness before, the diagnosis and the days of treatment given to the patient. Include all charges of service given to the patient and supply your provider ID on the appropriate lines. Indicate where the patient received treatment along with how many days of hospitalization was provided before signing and dating the form. Send the form to the insurance provider for proper compensation.