Top section of the CMS 1500 form
Box 1a - Required
Recipient ID Number
�� Enter the client’s eight-character prime identification number.
�� Enter the number exactly as it appears on the Medical Care Identification.
Box 2 - Required
Patient’s Name
�� Enter the client’s name exactly as it is printed on the Medical Care Identification.
�� Use the client’s last name first.
�� Do not use nicknames.
Box 9 - Optional
Third Party Resource
�� If the client has other medical coverage, enter the appropriate two-digit third party resource (TPR) explanation code.
�� A code must be listed when the other insurance did not make a payment.
�� A code is always required when the client has more than one other insurance carrier.
�� TPR codes can be found in your specific provider supplemental information.
Box 10 - Optional
Patient’s Condition
�� Check the appropriate box only when an injury is involved.
�� Do not check any boxes if there is no injury to report.
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