Professional Documents
Culture Documents
Workers Compensation
Workers Compensation
Insurance
Block
1
1a
2
3
4
5
6
7
8
BCBS
Medicare
x - in medicare box
Medicaid
enter x in
TRICARE/CHAMPUS
enter x in madicaid box box
enter sponsor's
social security
number as it
appears on the
reverse of the
uniformed services
common access
card.
ID #
Pt's
name
LAST, FIRST, MI
patients
birthdate
x - to indicate
gender
policy holder's last name, first
name, and middle initial
patients mailing address and
telephone number
x- to indicate the patients
relationship to policy holder
policyholder's mailing address
and telephone number
leave blank
Tricare
leave blank
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10a-c
10d
11
leave blank
policyholder's commercial
group number if the patient is
covered by a group health plan
11a
11b
12
leave blank.
policyholder's commercial
health insurance plan
x- in the NO box (if patient
does not have a secondary
insurance coverage)
enter SIGNATURE ON FILE.
Leave the date field blank
13
11c
11d
leave blank
if DD form 2527 is
attched to the
cmd-1500 claim
enter DD form
2527 attached.
Otherwise leave
blank
enter NONE
leave blank
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enter x in NO box
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14
15
16
17
17a
17b
18
19
leave blank
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20
21
22
23
24b
24c
leave blank
24a
E if service was
provided for medical
emergency regardless
of where it was
provided
24d
24e
24f
24g
24h
24l
24j
25
26
27
28
29
30
31
32
32a
32b
33
33a
33b
leave blank
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Worker's Comp
enter x in FECA box
leave blank
leave blank
enter claim number assined
by the worker's
compensation third party
payer
enter the name of the
worker's compensation payer
leave blank
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