US Insurance Billing Additional Resources

• Box 1 – Insurance Coverage Type
• The Top Right Corner – Carrier Block
• Box 12 – Patient's Signature
• Box 13 – Insured's Signature
• Box 4 – Insured's Name
• Box 2 – Patient's Name
• Box 7 – Insured's Address
• Box 31 – Signature of Physician or Supplier
• Box 3 – Patient's Birth Date and Sex
• Box 11 – Insured's Policy Group or FECA Number
• Box 5 – Patient's Address
• Box 6 – Patient Relationship to Insured
• Box 15 – Other Date
• Box 22 – Resubmission Code and Original Reference Number
• Box 14 – Date of Current Illness, Injury or Pregnancy (LMP)
• Box 23 – Prior Authorization Number
• Box 16 – Dates Patient Unable to Work
• Box 17 – Referring Provider
• Box 26 – Patient's Account Number
• Box 18 – Hospitalization Dates
• Box 19 – Additional Claim Information
• Box 20 – Outside Lab
• Box 27 – Accept Assignment
• Box 21 – Diagnosis Codes
• Box 9 – Other Insured's Name
• Box 10 – Is the Patient's Condition Related To
• Box 25 – Federal Tax ID Number
• Box 24 – Service Lines
• Box 29 – Amount Paid
• Box 32 – Service Facility Location
• Box 28 – Total Charge
• Box 33 – Billing Provider Info & Phone