CMS (HCFA) Form 1500 FAQ

Where can we get the CMS (HCFA) 1500 forms?

You can download the CMS (HCFA) 1500 form from our CalVCP forms page.

Where in the CMS (HCFA) 1500 form should the claim number be printed?

The claim number should be printed in field 1A on the CMS (HCFA) 1500 form.

Where does the claimant sign on the CMS (HCFA) 1500 form for the services received?

The claimant will not need to sign the CMS (HCFA) 1500 form for medical and dental services. And, the claimant does not have to sign the CMS (HCFA) for mental health services.

Where does a treating intern's name and license go?

Place the intern's name and license number in Box 24K.

Where does a supervising therapist sign and date? Where do they place their licensure?

The supervisor's signature or signature stamp, date and his/her licensure go in Box 31.