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| 11273054136 | 1. | Insurance type | 0 | |
| 11273054137 | 1a. | Insured's ID Number | 1 | |
| 11273054138 | 2. | Patient's name (last, first, middle inital) | 2 | |
| 11273054139 | 3. | Patient's DOB | 3 | |
| 11273054140 | 4. | Insured's name (last, first, middle inital) | 4 | |
| 11273054141 | 5. | Patient's address, city, state, zip, telephone number | 5 | |
| 11273054142 | 6. | Patient's relationship to insured | 6 | |
| 11273054143 | 7. | Insured's address, city, state, zip, telephone number | 7 | |
| 11273054144 | 8. | Reserved for NUCC use | 8 | |
| 11273054145 | 9. | Other insured's name (last, first, middle initial) | 9 | |
| 11273054146 | 9a. | Other insured's policy or group number | 10 | |
| 11273054147 | 9b. | Reserved for NUCC use | 11 | |
| 11273054148 | 9c. | Reserved for NUCC use | 12 | |
| 11273054149 | 10 | Is patient's condition related to: | 13 | |
| 11273054150 | 10a. | Employment | 14 | |
| 11273054151 | 10b. | Auto accident | 15 | |
| 11273054152 | 10c. | Other accident | 16 | |
| 11273054153 | 11. | Insured's policy group or feca number | 17 | |
| 11273054154 | 11a. | Insured's Date of Birth, Sex | 18 | |
| 11273054155 | 11b. | Other Claim ID (Designated by NUCC) | 19 | |
| 11273054156 | 11c. | Insurance plan name or program name | 20 | |
| 11273054157 | 11d. | Is there another health benefit plan? | 21 | |
| 11273054158 | 12. | Patients or authorized person's SIGNATURE Authorize the release of any medical or other information necessary to process this claim | 22 | |
| 11273054159 | 13. | Insured's or authorized persons signature, i authorize payment of medical benefits to the undersigned physician or supplier for services described below. | 23 | |
| 11275552318 | 14. | Date of current: illness, injury, or pregnancy (LMP) | 24 | |
| 11275552319 | 15. | Other date | 25 | |
| 11275552320 | 16. | Dates patient unable to work in current occupation | 26 | |
| 11275552321 | 17. | Name of referring provider other other source | 27 | |
| 11275552322 | 17a | Blank | 28 | |
| 11275552323 | 17b. | Referring provider's NPI | 29 | |
| 11275552324 | 18. | Hospitalization dates related to current services | 30 | |
| 11275552325 | 19. | Additional claim information (designated by NUCCI) | 31 | |
| 11275552326 | 20. | Outside lab? $ Charges | 32 | |
| 11275552327 | 21. | Diagnosis or nature of illness or injury | 33 | |
| 11275552328 | 22. | Resubmission code, original ref. No. | 34 | |
| 11275552329 | 23. | Prior authorization | 35 | |
| 11275552330 | 24a. | Dates of service | 36 | |
| 11275552331 | 24b. | place of service | 37 | |
| 11275552332 | 24c. | EMG | 38 | |
| 11275552333 | 24d. | Procedures, services, or supplies CPT/HCPCS, Modifers | 39 | |
| 11275552334 | 24e. | Diagnosis Pointer | 40 | |
| 11275552335 | 24f. | charges | 41 | |
| 11275552336 | 24g. | Days or Units | 42 | |
| 11275552337 | 24h. | EPSDT family plan | 43 | |
| 11275552338 | 24i. | ID Qual | 44 | |
| 11275552339 | 24j. | Rendering Provider ID # | 45 | |
| 11275552340 | 25. | Federal tax ID number SSN EIN | 46 | |
| 11275552341 | 26. | Patient's account no. | 47 | |
| 11275552342 | 27. | Accept assignment | 48 | |
| 11275552343 | 28. | Total charge | 49 | |
| 11275552344 | 29. | Amount paid | 50 | |
| 11275552345 | 30. | Rsvd for NUCCI Use | 51 | |
| 11275552346 | 31. | Signature or physician or supplier including degrees or credentials | 52 | |
| 11275552347 | 32. | Service facility location information | 53 | |
| 11275552348 | 32a. | NPI number for box 32 | 54 | |
| 11275552349 | 32b. | Leave blank | 55 | |
| 11275552350 | 33. | Billing provider info & ph # | 56 | |
| 11275552351 | 33a. | NPI# for box 33 | 57 |
