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CMS-1500 / HCFA Claim Form

Standard healthcare claim form for NEMT reimbursement

Your Name *

Your Email *

Your Phone

Insurance Type *

Insured's ID Number (Box 1a) *

Patient Name (Box 2) *

Date of Birth (Box 3)

Sex (Box 3)

Address (Box 5)

City

State

ZIP

A. Code 1 *

B. Code 2

C. Code 3

D. Code 4

Common NEMT codes: Z02.89, R69, Z76.89

Prior Authorization Number

Common NEMT procedure codes: T2003 (NEMT), A0426 (ALS), A0428 (BLS), A0130 (Wheelchair van)

No service lines. Add at least one to submit.

Federal Tax ID (Box 25)

Tax ID Type

Billing Provider Name (Box 33) *

Billing Provider NPI (Box 33a) *

Billing Provider Address

Facility Name (Box 32)

Facility Address

Facility NPI (Box 32a)

Total Charge (Box 28): $0.00