CMS 1500 claim form billing instruction Part 3

HCFA BOX BLOCK 9 OTHER INSURED'S NAME

CMS 1500 claim form billing instruction Part 2

CMS 1500 claim form billing instruction Part 1

Enter the last name, first name, and middle initial of the enrollee in a Medigap policy, if it is different from that shown in block 2. Otherwise, enter the word "SAME". If no Medigap benefits are assigned, leave blank. 

BLOCK 9A OTHER INSURED'S POLICY OR GROUP NUMBER
Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG or MGAP. 

BLOCK 9B OTHER INSURED'S DATE OF BIRTH

Enter the Medigap enrollee's birth date (MMDDCCYY) and sex. 

BLOCK 9C EMPLOYER'S NAME OR SCHOOL NAME