The CMS - 1500 form is to facilitate the process of billing by easily arrange in diagnoses and services provided that were necessary to treat patients. The form is divided into two major sections, patient and insured information and physician or supplier information. The upper portion of the form has 13 "Form Locators" ( boxes to be completed on the form) that contain 11 data elements and two signature form locators. The lower portion of the form consists of 20 form locators numbered 14 through 33 that contain 19 data elements, and one signature form locator.
Form Locator 1- type of insurance
Form Locator 1a - insured 's ID number
Form Locator 2 -patient 's name
Form locator 3 - patients date of birth/sex
Form Locator 4 - insured 's name
Form Locator 5 - patients address
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Form locator 10d - reserved for local use
Form Locator 11 - insured 's policy group or FECA number
Form Locator 11a - insured 's date of birth/sex
Form Locator 11b - employers name or school name
Form Locator 11c - insurance plan name or program name
Form Locator 11d - is there another health benefit plan?
Form Locator 12 - patients o authorized person 's signature
Form Locator 13 - insured 's or authorized person 's signature
Form Locator 14 - date of current illness, injury, pregnancy
Form Locator 15 - if patient has had same or similar illness
Form locator 16 - dates patient unable to work in current occupation
Form Locator 17 - name of referring physician