CMS 1500 Claim Forms - Chiropractor Claim Forms

 New 1500 CMS Claim Forms

Where to Put Your Focus
Every Physician Makes a Good Referral

As of April 1, 2014, Medicare will only process paper claims submitted on the revised CMS 1500 claim form

• Approved by the National Uniform Claim Committee (NUCC); HIPAA compliant
• This form was revised to align the paper form with some of the changes in the electronic health care claims: Professional (837), 005010X222 Technical Report Type 3 (5010) and 005010X222A1 Technical Report Type 3 (5010A1)
• The most significant change was the addition of 8 diagnosis codes in field 21
• Includes new QR code identifier at the top of the form that supports and aligns with Industry scanning systems
• Printed with OCR "dropout" red ink on 20lb. paper (per government regulations)
• Form not available personalized
• Certified Chain of Custody; promotes sustainable forest management
• Size: 8-1/2x11"

Available Formats

• 1 Part Continuous (for pin style printers)
• 2 Part (carbon copy) Continuous (for pin style printer
• Laser (for standard laser printers)