CMS 1500 Claim Forms

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Product Overview:
New 1500 CMS Claim Forms


As of April 1, 2014, Medicare will only process paper claims submitted on the revised CMS 1500 claim form
Allows healthcare providers to bill a patient's insurance company for reimbursement
  • Approved by the National Uniform Claim Committee (NUCC); HIPAA compliant
  • This form was revised to align the paper form with some of the changes in the electronic health care claims: Professional (837), 005010X222 Technical Report Type 3 (5010) and 005010X222A1 Technical Report Type 3 (5010A1)
  • The most significant change was the addition of 8 diagnosis codes in field 21
  • Includes new QR code identifier at the top of the form that supports and aligns with Industry scanning systems
  • Printed with OCR "dropout" red ink on 20lb. paper (per government regulations)
  • Form not available personalized
  • Certified Chain of Custody; promotes sustainable forest management
  • Size: 8-1/2x11"


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CMS 1500 Claim Forms
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Part Number(s): 796 0018, 796 0019, 796 0020, 796 0024, 796 0023, 796 0022

Mfg Part Number(s): 790-0129PK, 790-0116PK, 790-0120PK, 790-0116QR, 790-0129QR, 790-0120QR

Scrip Part Number(s): 796 0024, 796 0022, 796 0023, 796 0018, 796 0020, 796 0019


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