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Professional CMS-1500 Box Numbers

Updating Professional CMS-1500 Claim Forms (Box 1-33)
Box 1 - Plan Type
Box 1a - Insured's ID Number
Box 2 - Patient's Name
Box 3 - Patient's Birthdate, Sex
Box 4 - Insured's Name
Box 5 - Patient's Address
Box 6 - Patient Relationship to Insured
Box 7 - Insured's Address
Box 8 - Reserved for Use by the NUCC
Box 9 - Other Insured's Name
Box 9a - Other Insured’s Policy or Group Number
Box 9b - Reserved for NUCC Use
Box 9c - Reserved for NUCC Use
Box 9d - Insurance Plan Name or Program Name
Box 10a, 10b, 10c - Is Patients Condition Related To:
Box 10d - Claim Codes
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 - Is there another Health Benefit Plan?
Box 12 - Patient's or Authorized Person's Signature
Box 13 - Insured's or Authorized Person's Signature
Box 14 - Date of Current Illness, Injury or Pregnancy
Box 15 - Other Date
Box 16 - Dates Patient Unable to Work in Current Occupation
Box 17 - Name of Referring Provider or Other Source
Box 17a - Other ID#
Box 17b - Referring Provider NPI #

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