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Click link to access the Banner Page Archive http://www.vtmedicaid.com/Information/bannerarchives.html Banner Page February 14, 2014 Transition to the New CMS1500 Paper Claim Form Currently Vermont.

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Item 17b - Enter the NPI of the referring, ordering, or supervising physician or non- physician practitioner listed in item 17. All physicians and non-physician practitioners who order services or refer Medicare beneficiaries must report this data.

Box 17a. The Other ID number of the referring, ordering, or supervising provider is reported in 17a in the shaded area. The qualifier indicating what the number represents is reported in the qualifier field to the immediate right of 17a. LU Location Number (This qualifier is used for Supervising Provider only.)

Box 4 (if applicable): Insured's name is required to be entered here. It won't be required unless you are billing for an infant using the mother's ID. Box 7: This field requires you to enter the insured's address. The street address, area, state, ZIP code, and telephone number are included.

Box 13 is the “authorization of payment of medical benefits to the provider of service.” If this box is completed, the patient is indicating that they want any payments for the services being billed to be sent directly to the provider.

Box 14 - Date of Current Illness, Injury, or Pregnancy (LMP) Enter the applicable qualifier to identify which date is being reported.

How to fill out a CMS-1500 form The type of insurance and the insured's ID number. The patient's full name. The patient's date of birth. The insured's full name, if applicable. The patient's address. The patient's relationship to the insured, if applicable. The insured's address, if applicable. Field reserved for NUCC use.

32 Required Service Facility Location Information - Enter the provider name. Enter the provider address, without a comma between the city and state, and a nine-digit zip code, without a hyphen. Enter the telephone number of the facility where services were rendered, if other than home or office.

Billing Provider Information & Phone Number – name, address, and phone number of provider requesting to be paid for services rendered. Billing provider address on both a CMS 1500 and UB must be the physical location; not a PO Box.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232