CMS 1500 claim form billing instruction Part 4

BLOCK 11A INSURED'S DATE OF BIRTH

CMS 1500 claim form billing instruction Part 2

CMS 1500 claim form billing instruction Part 3

CMS 1500 claim form billing instruction Part 1

Enter the insured's birth date (MMDDCCYY) and sex, if different from block 3.
BLOCK 11B EMPLOYER'S NAME OR SCHOOL NAME
Enter the employer's name, if applicable. If there is a change in the insured's insurance status, e.g., retired, enter the six - digit retirement date (MMDDYY) preceded by the word "RETIRED."
Completion of this field is conditional when the beneficiary has insurance primary to Medicare. 

BLOCK 11C INSURANCE PLAN NAME OR PROGRAM NAME

Enter the complete insurance plan or program name, e.g., Blue Shield of (State). If the primary payer's EOB does not contain the claims processing address, record the primary payer's claims processing address directly on the EOB.
Completion of this field is conditional for insurance information primary to Medicare. 

BLOCK 11D IS THERE ANOTHER HEALTH BENEFIT PLAN

Leave blank. Not required by Medicare.

CMS 1500 - BLOCK 12 PATIENT OR AUTHORIZED PERSON'S SIGNATURE

The patient or an authorized representative must sign and enter the six - digit date (MMDDYY) for this block unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file. If the patient is physically or mentally unable to sign, a representative may sign on the patient's behalf. In this event, the statement's signature line must indicate the patient's name followed by: "by" the representative's name, address, relationship to the patient, and the reason the patient cannot sign the form. The signature on file authorization is effective indefinitely unless patient or the patient's representative revokes the arrangement.

The patient's signature authorizes the release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service and (or) supplier, when the provider of service and (or) supplier accepts assignment on the claim.

Signature By Mark (X) - When an illiterate or physically handicapped enrollee signs by mark, a witness must sign his/her name and address next to the mark.

Signature on File Providers of service and (or) suppliers are permitted to obtain and retain on file a lifetime authorization from the beneficiary. This authorization allows the provider of service and (or) supplier to submit assigned and non-assigned claims on the beneficiary's behalf.

BLOCK 13 INSURED'S OR AUTHORIZED PERSON'S SIGNATURE

The signature in this block authorizes payment of mandated Medigap benefits to the participating provider of service and (or) supplier if required Medigap information is included in block 9 and its subdivisions. The patient or his/her authorized representative signs this block, or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating physician/supplier's office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.