CMS-1500 Reference Page

Patient and Insurance Information

Provider and Services Information

Box 1 – Insurance Plan Type Box 1a - Insured's I.D. Number Box 2 - Patient's Name Box 3 - Patient's Birth Date, Sex Box 4 - Insured's Name Box 5 - Patient's Address Box 6 - Patient Relationship to Insured Box 7 - Insured's Address Box 8 - Not Available in TheraPlatform Box 9 - Other Insured's Name Box 9a - Other Insured's Policy or Group Number Box 9b & 9c - Not Available in TheraPlatform Box 9d - Insurance Plan Name or Program Name Box 10a, b, c - Is Patient's Condition Related To Box 10d - Not Available in TheraPlatform Box 11 - Insured's Policy, Group, or FECA Number Box 11a - Insured's Date of Birth, Sex Box 11b - Other Claim ID Box 11c - Insurance Plan Name or Program Name Box 11d - Secondary Insurance Box 12 - Patient/Authorized Person's Signature Box 13 - Insured/Authorized Person's Signature

Box 14  Onset date 15 & 16 - Not Available in TheraPlatform Box 17 - Name of Referring Provider Box 17a - Reffering provider additional Id Box 17b - NPI# Box 18, 20 - Not Available in TheraPlatform              Box 19 - Additional Claim Information Box 21 - Diagnosis or Nature of Illness or Injury Box 22 - Not Available in TheraPlatform Box 23 - Prior Authorization Number Section 24 - Service Lines Box 25 - Federal Tax ID Number Box 26 - Patient's Account No. Box 27 - Accept Assignment? Box 28 - Total Charge Box 29 - Amount Paid Box 31 - Not Available in TheraPlatform Box 32 - Service Facility Location Information Box 32a - NPI# Box 32b - Not Available in TheraPlatform Box 33 - Billing Provider Info & Phone # Box 33a - NPI# Box 33b - Not Available in TheraPlatform