HCFA-1500 Tutorial for ChiroPulse.     Click here for more HCFA information, customization & overrides.

1 Insurance Type  
2 Px Name (Last, F, Mi) 3 Px DOB
5 Px Address 6 Px Rel to Ins
5 City 8 Single/Married/O
5 Zip & Phone # 8 Employed/FTS/PTS
9 Other Insured's Name (Last, F, Mi)  
9a Other Ins. Policy / Group # 10a Emp Y/N
9b Other Ins DOB & Gender 10b Auto Y/N
9c Employer's Name 10c Other Acc Y/N
9d Ins Plan/Program Name 10d Reserve for Local

12 Signature on File & Date
.

14 Date of Current Illness 15 Date of Similar ill
17 Ref Physician 17a ID # Ref Phys
19 Reserved for Local Use
21-1 ICD #1 21-3 ICD #3
21-2 ICD #2 21-4 ICD #4
24-A B C 24-D 24-D 24-E
             
06 06 1999   11 3 98940 51 1, 2, 3
             
             
             
             
25 Fed Tax ID# 26 Px Act # 27 Assign Y/N
31 Physician Signature
& Date		 32 Name & Address
of Service Facility

 
1a Insured's ID #
4 Insured's Name (Last, F. Mi.)
7 Insured's Address
7 Insured's City
7 Insured's Zip & Tel #
11 Ins Policy Group FECA #
11a Ins. DOB & Gender
11b Employer Name
11c Insurance Plan Name
11d Another Health Benefit

13 Ins Auth. Signature
.

16 Work F To
18 Hosp F To
20 Out Lab $ Charges
22 Med. Resub Ref #
23 Prior Authorization #
24-F G H I J K
           
40.00 1       123123
           
           
           
           
28. $ Chg 29. $ Pd 30. $ Bal
33 Physicians Name
Address & Phone