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Commonly used forms:
HCFA-1500:
HCFA-1500:
UB-04:
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names should match
Box 3 Enter the patient’s full date of birth MM/DD/CCYY and sex (check the box for male or female).
Box 4 Enter the insured’s full name as it appears on the ID card. This may be different than the
patient. (Beware of
nicknames. The names should match exactly.)
Box 5 Enter the patient’s address.
Box 6 Check the box for the patient’s relationship to the insured.
Box 7 Enter the insured’s address.
Box 8 Enter the marital status and employment status for the patient by checking the appropriate
boxes here.
Box 9 Enter the name of any secondary insurance policy the patient may be covered under.
Box 9a Enter the other insurance policy (if applicable).
Box 9b Enter the other insured’s date of birth and sex (if applicable).
Box 9c Enter the employer’s name for the secondary insurance policy.
Box 9d Enter the insurance plan name for the secondary policy.
Box 10 a–c Check the boxes that apply regarding the patient’s employment, auto accident, or
other accident.
Box 11 Enter the insured’s policy or group number for the primary insurance.
Box 11a Enter the insured’s date of birth and sex for the primary policy.
Box 11b Enter the employer’s name for the primary policy.
Box 11c Enter the insurance company or plan name for the primary policy.
Box 11d Is there another benefit plan (referring to secondary insurance)? If yes, then answer boxes
9-9d. If not, then
skip.
Box 12 Patient or Guardian signature. You can enter “Signature on File” if you have the patient’s
original signature
on file at your office. Enter the date.
Box 13 Insured’s signature.
Box 14 Enter the first date of the current illness or injury. For instance, if this is ongoing treatment
due to a car
accident, enter the date of the accident here. If it due to an illness, enter the date of the onset of
the illness.
Box 15 If the patient has had the same or similar illness, enter date. For instance, if the patient has
cancer and has
been in remission, enter the date the cancer was first diagnosed here.
Box 16 Enter the dates the patient is unable to work, i.e. disabled from work due to illness or injury.
Box 17 Name of referring physician or other source.
Box 17a ID number of referring physician. (Call the office of that physician for this information.)
Box 18 Hospitalization dates (if applicable).
Box 19 Reserved for local use—leave blank unless instructed by an insurance company to use this
field for specific
information.
Box 20 Outside Lab? Mark yes only of you sent a specimen to a lab you are not associated with for
processing. Also
enter the charges for this service.
Box 21 Enter the diagnosis for the patient. This will be the ICD-9 code, not the description. You
can enter up to four
diagnoses.
Box 22 Medicaid resubmission code—reserve this space specifically for Medicaid patient
resubmissions.
Box 23 Enter the prior authorization number, if necessary, that you received before you saw the
patient, if required
by the insurance company.
Box 24a Enter the date of service.
Box 24b Enter the place of service (see Appendices Section for approved list).
Box 24c Enter the type of service.
Box 24d Enter the CPT procedure codes for the services provided.
Box 24e Enter the diagnosis code, referencing the ICD-9 code in Box 21. For instance, if this
procedure refers to the
diagnosis code in the #2 spot, enter a 2 here.
Box 24f Enter the charges.
Box 24g Enter the days or units.
Box 24h Enter if this is related to family planning (birth control).
Box 24i Enter if this is related to EMG (Emergency Medical Group). Is this related to an emergency
service of any
kind?
Box 24j Enter if this is related to COB (Coordination of Benefits).
Box 24k Reserved for local use—leave blank unless instructed to use this field by an insurance
carrier.
Box 25 Enter your Federal Tax ID# and indicate whether it is a Social Security number of a federal
Tax ID #.
Box 26 Enter your Patient Account Number.
Box 27 Accept Assignment for this claim? Check Yes or No.
Box 28 Enter the total charges for this claim.
Box 29 Enter the amount paid by the primary carrier, if this is a claim to the secondary payer.
Box 30 Enter the balance due if this is a claim to the secondary payer.
Box 31 Enter the physician’s signature here. A rubber stamp is acceptable but “Signature on File” is
generally not.
Box 32 Enter the name and address of the facility where the services are rendered. If this is an
office visit, enter your
office address.
Box 33 Enter the physician’s billing name (if a corporation, enter the corp name), address, and
phone number. At the
bottom, enter the Provider ID # and Group # (assigned by the insurance company). In 2007, the
physician’s license
number (issued state by state) will be replaced with a new National Physician’s Index (NPI) number
for more
uniform billing.
Box 3 Enter the patient’s full date of birth MM/DD/CCYY and sex (check the box for male or female).
Box 4 Enter the insured’s full name as it appears on the ID card. This may be different than the
patient. (Beware of
nicknames. The names should match exactly.)
Box 5 Enter the patient’s address.
Box 6 Check the box for the patient’s relationship to the insured.
Box 7 Enter the insured’s address.
Box 8 Enter the marital status and employment status for the patient by checking the appropriate
boxes here.
Box 9 Enter the name of any secondary insurance policy the patient may be covered under.
Box 9a Enter the other insurance policy (if applicable).
Box 9b Enter the other insured’s date of birth and sex (if applicable).
Box 9c Enter the employer’s name for the secondary insurance policy.
Box 9d Enter the insurance plan name for the secondary policy.
Box 10 a–c Check the boxes that apply regarding the patient’s employment, auto accident, or
other accident.
Box 11 Enter the insured’s policy or group number for the primary insurance.
Box 11a Enter the insured’s date of birth and sex for the primary policy.
Box 11b Enter the employer’s name for the primary policy.
Box 11c Enter the insurance company or plan name for the primary policy.
Box 11d Is there another benefit plan (referring to secondary insurance)? If yes, then answer boxes
9-9d. If not, then
skip.
Box 12 Patient or Guardian signature. You can enter “Signature on File” if you have the patient’s
original signature
on file at your office. Enter the date.
Box 13 Insured’s signature.
Box 14 Enter the first date of the current illness or injury. For instance, if this is ongoing treatment
due to a car
accident, enter the date of the accident here. If it due to an illness, enter the date of the onset of
the illness.
Box 15 If the patient has had the same or similar illness, enter date. For instance, if the patient has
cancer and has
been in remission, enter the date the cancer was first diagnosed here.
Box 16 Enter the dates the patient is unable to work, i.e. disabled from work due to illness or injury.
Box 17 Name of referring physician or other source.
Box 17a ID number of referring physician. (Call the office of that physician for this information.)
Box 18 Hospitalization dates (if applicable).
Box 19 Reserved for local use—leave blank unless instructed by an insurance company to use this
field for specific
information.
Box 20 Outside Lab? Mark yes only of you sent a specimen to a lab you are not associated with for
processing. Also
enter the charges for this service.
Box 21 Enter the diagnosis for the patient. This will be the ICD-9 code, not the description. You
can enter up to four
diagnoses.
Box 22 Medicaid resubmission code—reserve this space specifically for Medicaid patient
resubmissions.
Box 23 Enter the prior authorization number, if necessary, that you received before you saw the
patient, if required
by the insurance company.
Box 24a Enter the date of service.
Box 24b Enter the place of service (see Appendices Section for approved list).
Box 24c Enter the type of service.
Box 24d Enter the CPT procedure codes for the services provided.
Box 24e Enter the diagnosis code, referencing the ICD-9 code in Box 21. For instance, if this
procedure refers to the
diagnosis code in the #2 spot, enter a 2 here.
Box 24f Enter the charges.
Box 24g Enter the days or units.
Box 24h Enter if this is related to family planning (birth control).
Box 24i Enter if this is related to EMG (Emergency Medical Group). Is this related to an emergency
service of any
kind?
Box 24j Enter if this is related to COB (Coordination of Benefits).
Box 24k Reserved for local use—leave blank unless instructed to use this field by an insurance
carrier.
Box 25 Enter your Federal Tax ID# and indicate whether it is a Social Security number of a federal
Tax ID #.
Box 26 Enter your Patient Account Number.
Box 27 Accept Assignment for this claim? Check Yes or No.
Box 28 Enter the total charges for this claim.
Box 29 Enter the amount paid by the primary carrier, if this is a claim to the secondary payer.
Box 30 Enter the balance due if this is a claim to the secondary payer.
Box 31 Enter the physician’s signature here. A rubber stamp is acceptable but “Signature on File” is
generally not.
Box 32 Enter the name and address of the facility where the services are rendered. If this is an
office visit, enter your
office address.
Box 33 Enter the physician’s billing name (if a corporation, enter the corp name), address, and
phone number. At the
bottom, enter the Provider ID # and Group # (assigned by the insurance company). In 2007, the
physician’s license
number (issued state by state) will be replaced with a new National Physician’s Index (NPI) number
for more
uniform billing.
Form Locator 6. Statement Covers Period.(MMDDYY)
Form Locator 7. Reserved
Form Locator 8a. Patient name. Last, First and Middle Initial. Form Locator 8b. Patient Identifier
Form Locator 9a. Patient Address.
Form Locator 9b. City
Form Locator 9c. State
Form Locator 9d. Zip
Form Locator 9e. Country code
Form Locator 10. Patient Birth Date. (MMDDYYYY)
Form Locator 11. Patient Sex.
Form Locator 12. Admission/Start of Care Date (MMDDYY)
Form Locator 13. Admission Hour
Form Locator 14. Priority (Type) of Visit
Form Locator 15. Source of Referral for Admission or Visit
Form Locator 16. Discharge Hour
Form Locator 17. Patient Discharge Status
Form Locator 18 - 28. Condition Codes
Form Locator 29. Accident State
Form Locator 30. Reserved
Form Locator 31- 34. Occurrence Code and Date.
Form Locator 35-36. Occurrence Span Code and Dates.
Form Locator 37. Reserved
Form Locator 38. Responsible Party Name and Address.
Form Locator 39-41. Value Codes and Amounts.
Form Locator 42. Revenue Codes. Must be valid UB04 codes
Form Locator 43. Revenue Description
Form Locator 43. Page_ of_
Form Locator 44. HCPCS/Rates/HIPPS Code
Form Locator 45. Service Date
Form Locator 45. Creation date
Form Locator 46. Service Units
Form Locator 47. Total Charges (Cannot be a negative number.)
Form Locator 48. Non Covered charges (Cannot be a negative number.)
Form Locator 49. Reserved
Form Locator 50 a-c. Payer Name
Form Locator 51a-c. Health Plan ID Number
Form Locator 52a-c. Release of Information Certification Indicator
Form Locator 53a-c. Assignment of Benefits Certification indicator (“Y”, “N” or ”W ”)
Form Locator 54 a-c. Prior Payments (Other Payer Amounts)
Form Locator 55 a-c. Estimated Amount Due (Payer)
Form Locator 56. National Provider Identifier - Billing Provider
Form Locator 57 a-c. Other (Billing) Provider ID (Secondary Provider Numbers used to identify the
provider per payer)
Form Locator 58 a-c. Insured’s Name
Form Locator 59 a-c. Patients Relationship to the Insured
Form Locator 60 a-c. Insured’s Unique ID
Form Locator 61 a-c. Insured’s Group Name
Form Locator 62 a-c. Insured’s Group Number
Form Locator 63 a-c. Treatment Authorization Code. Form Locator 64 a-c. Document Control
Number.(Payers Original Claim Number)
Form Locator 65a-c. Employer Name (of the Insured)
Form Locator 66. Diagnosis and Procedure Code Qualifier (ICD Version Indicatory)
Form Locator 67. Principal Diagnosis Code and Present on Admission Indicator. (Required)
Form Locator 67a-q. Other Diagnosis codes. V and E codes are appropriate.
Form Locator 68a. Reserved
Form Locator 68b. Reserved
Form Locator 69. Admitting Diagnosis
Form Locator 70a-c. Patient’s reason for visit
Form Locator 71. Prospective Payment System (PPS) Code (Used by Medicare)
Form Locator 72 a-c. External cause of injury code (ECI). (The first E-code should always be printed
here.)
Form Locator 73. Reserved
Form Locator 74. Principal Procedure Code and Date
Form Locator 74a-e. Other Procedure Codes and Dates
Form Locator 75. Reserved
Form Locator 76. Attending Provider Name and Identifiers
Line 1: The National Provider ID/Secondary Identifier Qualifier/Secondary Identifier Secondary
Identifier = Contract Number with Payer Line 2: Attending Physician’s last name, first name.
Form Locator 77. Operating Physician Name and Identifier
Line 1: The National Provider ID/Secondary Identifier Qualifier/Secondary Identifier Secondary
Identifier = Contract Number with Payer Line 2: Operating Physician’s last name, first name.
Form Locator 78. Other Provider (Individual) Names and Identifiers
Line 1: The National Provider ID/Secondary Identifier Qualifier/Secondary Identifier
Secondary Identifier = Contract Number with Payer
Line 2: Other Physician’s last name, first name.
Form Locator 79. Other Provider (Individual) Names and Identifier
Line 1: The National Provider ID/Secondary Identifier Qualifier/Secondary Identifier
Secondary Identifier = Contract Number with Payer
Line 2: Other Physician’s last name, first name.
Form Locator 80. Remarks Field
Form Locator 81 a-d. Code-Code Field
Form Locator 7. Reserved
Form Locator 8a. Patient name. Last, First and Middle Initial. Form Locator 8b. Patient Identifier
Form Locator 9a. Patient Address.
Form Locator 9b. City
Form Locator 9c. State
Form Locator 9d. Zip
Form Locator 9e. Country code
Form Locator 10. Patient Birth Date. (MMDDYYYY)
Form Locator 11. Patient Sex.
Form Locator 12. Admission/Start of Care Date (MMDDYY)
Form Locator 13. Admission Hour
Form Locator 14. Priority (Type) of Visit
Form Locator 15. Source of Referral for Admission or Visit
Form Locator 16. Discharge Hour
Form Locator 17. Patient Discharge Status
Form Locator 18 - 28. Condition Codes
Form Locator 29. Accident State
Form Locator 30. Reserved
Form Locator 31- 34. Occurrence Code and Date.
Form Locator 35-36. Occurrence Span Code and Dates.
Form Locator 37. Reserved
Form Locator 38. Responsible Party Name and Address.
Form Locator 39-41. Value Codes and Amounts.
Form Locator 42. Revenue Codes. Must be valid UB04 codes
Form Locator 43. Revenue Description
Form Locator 43. Page_ of_
Form Locator 44. HCPCS/Rates/HIPPS Code
Form Locator 45. Service Date
Form Locator 45. Creation date
Form Locator 46. Service Units
Form Locator 47. Total Charges (Cannot be a negative number.)
Form Locator 48. Non Covered charges (Cannot be a negative number.)
Form Locator 49. Reserved
Form Locator 50 a-c. Payer Name
Form Locator 51a-c. Health Plan ID Number
Form Locator 52a-c. Release of Information Certification Indicator
Form Locator 53a-c. Assignment of Benefits Certification indicator (“Y”, “N” or ”W ”)
Form Locator 54 a-c. Prior Payments (Other Payer Amounts)
Form Locator 55 a-c. Estimated Amount Due (Payer)
Form Locator 56. National Provider Identifier - Billing Provider
Form Locator 57 a-c. Other (Billing) Provider ID (Secondary Provider Numbers used to identify the
provider per payer)
Form Locator 58 a-c. Insured’s Name
Form Locator 59 a-c. Patients Relationship to the Insured
Form Locator 60 a-c. Insured’s Unique ID
Form Locator 61 a-c. Insured’s Group Name
Form Locator 62 a-c. Insured’s Group Number
Form Locator 63 a-c. Treatment Authorization Code. Form Locator 64 a-c. Document Control
Number.(Payers Original Claim Number)
Form Locator 65a-c. Employer Name (of the Insured)
Form Locator 66. Diagnosis and Procedure Code Qualifier (ICD Version Indicatory)
Form Locator 67. Principal Diagnosis Code and Present on Admission Indicator. (Required)
Form Locator 67a-q. Other Diagnosis codes. V and E codes are appropriate.
Form Locator 68a. Reserved
Form Locator 68b. Reserved
Form Locator 69. Admitting Diagnosis
Form Locator 70a-c. Patient’s reason for visit
Form Locator 71. Prospective Payment System (PPS) Code (Used by Medicare)
Form Locator 72 a-c. External cause of injury code (ECI). (The first E-code should always be printed
here.)
Form Locator 73. Reserved
Form Locator 74. Principal Procedure Code and Date
Form Locator 74a-e. Other Procedure Codes and Dates
Form Locator 75. Reserved
Form Locator 76. Attending Provider Name and Identifiers
Line 1: The National Provider ID/Secondary Identifier Qualifier/Secondary Identifier Secondary
Identifier = Contract Number with Payer Line 2: Attending Physician’s last name, first name.
Form Locator 77. Operating Physician Name and Identifier
Line 1: The National Provider ID/Secondary Identifier Qualifier/Secondary Identifier Secondary
Identifier = Contract Number with Payer Line 2: Operating Physician’s last name, first name.
Form Locator 78. Other Provider (Individual) Names and Identifiers
Line 1: The National Provider ID/Secondary Identifier Qualifier/Secondary Identifier
Secondary Identifier = Contract Number with Payer
Line 2: Other Physician’s last name, first name.
Form Locator 79. Other Provider (Individual) Names and Identifier
Line 1: The National Provider ID/Secondary Identifier Qualifier/Secondary Identifier
Secondary Identifier = Contract Number with Payer
Line 2: Other Physician’s last name, first name.
Form Locator 80. Remarks Field
Form Locator 81 a-d. Code-Code Field
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