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Checkpoint: Complete a CMS-1500 Claim Form
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Complete the CMS-1500 claim form worksheet located in Appendix C. If you believe information provided in the following list is insufficient to adequately fill a required field with data, for example, to supply a specific diagnosis code, indicate this by typing N/A.
Name: Jane Smith
Insurer: TRICARE
Policy Number: 123456
ID number: 999000666
DOB: 01/01/1950
Gender: Female
Insured: James Smith, spouse
Address: 1111 Noname Court, Nowhere, NY 22222
Marital Status: Married
Patient’s Employer: Homemaker
Spouse’s Employer: U.S. Army
Nature of Condition: Routine exam
Patient Signature
