CMS 1500 Claim Form | PDF

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Sample

Currently the CMS 1500 Claim form must be ordered from the USBookstore Online | Read Fact Sheet.

Make a Paper Claim (After Ordering the Form)

You will find that the claim form is split into three sections. One must print or type the form in black ink. Don’t use any punctuation except where it is requested and remain inside the lines.

The information requested on the form is for the most part pretty easy and straight forward. There are some rules however that you must remember as you are completing your form. If you fail to remember these rules, it’s likely to cause a delay in processing your claim.

All of the date formats must be written in the MM/DD/YYYY format, regardless of the fact that some will ask for MMDDYY format, please disregard this. Please be aware that there is a “no exceptions” rule to white out or crossed out information. If white out is applied or if anything is crossed out, your claims form will be considered void and it will be returned to you.

You must only place an X in the boxes requesting a selection. Check marks are not acceptable.

You will not only find the link to the actual claim form but also a manual that will assist you in the event you aren’t sure about any specific inquiry. Keep the manual in a separate tab or print the pages you need prior to completing your form.