Terms : Hide Images
| 10680168617 | Black 1 | Type of insurance coverage | 0 | |
| 10680168618 | The insured's name is found in block | Block4 | 1 | |
| 10680168619 | Patients name | Block 2 | 2 | |
| 10680168620 | The insured address in block 7 refer to | Policyholders address | 3 | |
| 10680168621 | The physicians office place of service code | 11 | 4 | |
| 10680168622 | Physicians signature | 31 | 5 | |
| 10680168623 | The assignment is benefits | Block 13 | 6 | |
| 10680168624 | Procedures performed | 24d | 7 | |
| 10680168625 | The onset of illness | Block 14 | 8 | |
| 10680168626 | The billing provider NPI # | 33A | 9 | |
| 10680168627 | A secondary insurance is | 11d | 10 | |
| 10680168628 | When completing CMS1500 form, which contains indie about the patient and insured | Section 2 | 11 | |
| 10680168629 | Which is a fixed amount per visit and is typically paid at the time of medical services | Copayment | 12 | |
| 10680168630 | Block 14 | Date of current illness injury or pregnancy | 13 | |
| 10680168631 | Block17 | Name of referring provider and NPI # | 14 | |
| 10680168632 | Block21 | Diagnosis or nature of illness or injury | 15 | |
| 10680168633 | Block18 | Hospitalization dates related to current services | 16 | |
| 10680168634 | Block23 | Prior authorization number | 17 |
