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READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT'S OR AUTHORIZED PERSON'S FORM HCFA-1500 (12-90), FORM RRB-1500,. FORM OWCP-1500. Page 1. PLEASE PRINT OR TYPE. APPROVED OMB-0938-1197 FORM 1500 (02-12)BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BY. APPLICABLE PROGRAMS. NOTICE: Any person who APPROVED OMB-0938-0999 FORM CMS-1500 (08-05). Page 2. BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS The Center of Medicaid and Medicare Services (CMS) form 1500 must be used to bill SFHP for medical services. discharged, leave the discharge date blank. HEALTH INSURANCE CLAIM FORM. APPROVED BY NATIONAL UNIFOAM CLAIM COMMITTEE {NUCC) 02/12. ITT PICA. 11. MEDICARE MEDICAID TAICARE. CHAMPVA GROUP. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other CMS 1500. Form Title. Health Insurance Claim Form. Revision Date. 2012-02-01. O.M.B. #. 0938-1197. O.M.B. Expiration Date. 2023-10-31. CMS Manual.

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