Did you know that 92 percent of Americans have health insurance, as reported by Statista? That’s a significant number! As a result, medical billing has become an essential part of everyday tasks for healthcare practices. While most practitioners didn’t choose medicine to deal with paperwork, filling out the Health Care Financing Administration – HCFA 1500 form, which is the primary medical claim form, is relatively easy work. In this guide, we’ll walk you through the process of the HCFA form.

Americans Health Insurance And Medical Billing

What is the HCFA form?

The CMS 1500 form, also referred to as the HCFA 1500 form, is a standardized paper claim form that healthcare providers use to submit claims for services provided to patients covered by Medicare, Medicaid, and most private insurance companies. The document was initially developed by the HCFA, which is now known as the CMS. 

Hcfa Form

The health insurance claim form 1500 collects essential details about the patient, provider, services provided, diagnosis codes, charges, and payment information. This standardized layout enables insurance companies to process data efficiently, ensuring that healthcare providers receive timely reimbursement.

Who fills out an HCFA form?

Here are the different types of individual practitioners who can fill out and submit HCFA forms: 

  • Doctors 
  • Specialist 
  • Nurse practitioners 
  • Nurse-midwives 
  • Certified nurse anesthetic practitioners 
  • Physician assistants 
  • Clinical psychologists 
  • Clinical social workers 
  • Ambulance services 
  • Laboratory services

Practitioners Involved In Hcfa Form

Purpose of HCFA Form

The HCFA 1500 form serves the purpose of submitting claims for medical services provided by healthcare providers to patients. It is utilized to request payment from insurance carriers for the services rendered. Healthcare providers use this form to submit claims for reimbursement to insurance carriers, which includes Medicare and Medicaid.

Purpose Of Hcfa Form

How to Fill Out a Health Insurance Claim Form

The HCFA form consists of 33 boxes. But don’t worry; each box only requires a small amount of information, most of which is primary. And to make things even easier, we’ve created a billing guide for HCFA that will help you breeze through the process. Each entry in the guide corresponds to a specific box on the HCFA form:

1. Insurance information: 

Specify whether it’s Medicaid, Medicare, or the patient’s private insurer, along with their insurance ID, which goes in box 1a. 

2. Patient’s name: 

Simply write the patient’s full legal name. 

3. Patient’s sex and date of birth: 

Write the month, date, and year using two digits each. Also, check the appropriate box for the patient’s assigned sex at birth. 

4. Insured’s name: 

If the patient is using their insurance plan, you can leave this box empty. However, if the program is under someone else’s name, write that name here. 

5. Patient’s address and phone number: 

Fill out each box in this section with the correct information.

6. Patient’s relationship to the insured: 

Please select the appropriate box. Remember to choose only one out of the four boxes available. 

7. Insured’s address: 

If the patient is self-insured, please leave this box empty. However, if the patient is covered under someone else’s insurance plan, kindly provide the address of the insured person. 

8. Patient status:

In the first row (marital status), please check one box that best describes the patient’s current marital status. In the second row (employment status), please check one box that indicates the patient’s current employment status.

9. Other insurance information:

If the patient only has primary insurance, as mentioned earlier on the form, you can leave this section blank. However, if the patient has secondary insurance, please provide all the requested information here. 

10. Patient condition and Medicaid information: 

In this section, please indicate whether the services you provided were in response to injuries or illnesses sustained on the job, in a car accident, or another type of accident. Additionally, if the patient has a Medicaid number, please include it in the “reserved for local use” box.

11. Insured’s policy or group number: 

Please make sure to write down the patient’s policy, group, or Federal Employees’ Compensation Act number. Don’t forget to include the requested identifying information. If you have provided information in box 9, remember to check “yes” in box 11d. 

12. Patient’s signature: 

Every HCFA form requires the patient’s signature for submission. This is where you will record that signature. 

13. Insured’s signature: 

You only need to fill out this section if the patient has secondary insurance, as indicated in box 9. 

14. Date of condition being treated: 

Write down the date when the patient first started experiencing symptoms. 

15. Previous reports of conditions being treated: 

If the date of the patient encounter you are billing for is not the first instance of this condition, please record the first date here instead. However, if this is indeed the patient’s first time with symptoms, write down the date of the encounter you are billing for. 

16. Dates out of work: 

If the patient’s condition has caused them to be unable to work, include the dates when the patient has been sidelined.

17. Referring provider:

In case another practitioner referred the patient to you, kindly mention the name, ID number, and National Provider Identifier (NPI) of that practitioner. 

18. Hospitalization dates: 

If the patient’s condition has resulted in their hospitalization, please provide the dates of hospitalization here. 

19. Reserved for local use: 

Please keep this section blank as it is intended for the recipient of the form if needed. 

20. Outside lab charges: 

If you are submitting a claim for third-party lab tests, mark the “yes” box and indicate the charge amount. 

21. CPT codes: 

Please list the CPT codes that correspond to the services provided. You can utilize the lines under “Diagnosis Pointer” to include additional codes if necessary. 

22. Medicaid resubmission code: 

If you are resubmitting a rejected claim to Medicaid, write the reference number of the original claim in this space. 

23. Prior authorization number: 

If your patient brought prior authorization from the payer to their appointment, please include the authorization number here. Additionally, for investigational devices, provide a seven-digit IDE number, and for ambulance services, give the ZIP code.

24. Service details: 

In this section, you will provide the dates and location of the service, along with the services offered and the corresponding charges. Additionally, you will complete the diagnosis pointer section that you first encountered in box 21. Please note that if you are administering influenza or pneumococcal vaccines, you can leave this box blank. 

25. Tax identifier: 

Please provide your employer identification number (EIN) or, if you are a sole practitioner without an EIN, your Social Security number. 

26. Patient account number: 

While it is optional to complete this box, writing your patient’s account number within your practice can help you link the claim with the patient and track progress accordingly. 

27. Accept assignment: 

For physician, laboratory, surgical, supplier, or ambulance services, please check the “yes” box. 

28. Total charges: 

Write down the total amount of reimbursement you are seeking. 

29. Amount paid: 

If a portion of the claim has already been paid, indicate that amount here. 

30. Balance due: 

Subtract the value in box 29 from box 28, and write the resulting amount here. 

31. Provider signature: 

Please sign your HCFA form in this section. 

32. Service facility location information: 

Write down the complete address of the location where the services were provided. 

33. Service provider information: 

In this section, list your address again, along with your NPI and phone number. You have now completed your 1500 billing form.


The HCFA 1500 form is a crucial tool for healthcare providers to request reimbursement from insurance carriers. By carefully following the instructions on how to complete the form, healthcare providers can guarantee that all required details are provided and that the form is submitted accurately. The HCFA form offers a standardized approach for submitting claims and receiving payment for medical services, simplifying the process for healthcare providers to get compensated for their services.

Healthcare Claim Processing


author avatar

Isaac Smith

My name isaac and I am a revenue cycle management strategist with more than 10 years of experience. I completed my Bachelor in Medical and Health Services Management from Kean University and have worked extensively in the field of healthcare.

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