Cms 1500 Claim Filing Instructions (Page 4 of 9) in pdf

Cms 1500 Claim Filing Instructions Page 4

Required for

Insured’s or Authorized Person’s Signature

participating

Indicates if the patient (or legal guardian) or the subscriber

providers

authorizes this bill to be paid directly to the provider for the

services billed on the claims.

Required if

Date of current: Illness (first symptom) or injury (accident) or

applicable

Pregnancy (LMP)

Indicates in MM/DD/CCYY format if any of the following

conditions apply to the claim. Please check appropriate box.

Illness- Date of onset of the first symptom for the service billed

on the claim.

Injury- Date the accident occurred for the service billed on the

claim.

Pregnancy- Date of the patient’s last menstrual period prior to

the date of service.

Not Required

If Patient Has Had Same or Similar Illness, Give First Date

MM/DD/CCYY format of the date the patient experienced the

same or similar symptoms as the primary diagnosis billed.

Not Required

Dates Patient Unable To Work In current Operation

MM/DD/CCYY format of the date the patient’s work is affected by

the primary diagnosis billed, from the start date to the return

date.

Required if

Name of Referring Provider or Other Source

applicable

Name of the physician (primary or other), referring the patient to

the provider submitting this claim. PCP’s name required on claims

for managed care members.

Cms 1500 Claim Filing Instructions Page 4