CMS 1500 Claim Form PDF
The CMS-1500 form is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.
CMS 1500 Claim Form Download
It is also used for billing of some Medicaid State Agencies. Please contact your Medicaid State Agency for more details. The National Uniform Claim Committee (NUCC) is responsible for the design and maintenance of the CMS-1500 form. CMS does not supply the form to providers for claim submission.
In order to purchase claim forms, you should contact the U.S. Government Printing Office at 1-866-512-1800, local printing companies in your area, and/or office supply stores. Each of the vendors above sells the CMS-1500 claim form in its various configurations (single part, multi-part, continuous feed, laser, etc).
Download the CMS 1500 Claim Form in PDF format using the link given below.
