Checkpoint: Complete a CMS-1500 Claim Form Complete the CMS-1500 claim form worksheet located in Appendix C. If you believe information provided in the following list is insufficient to adequately fill a required field with data, for example, to supply a specific diagnosis code, indicate this by typing N/A. Name: Jane Smith Insurer: TRICARE Policy Number: 123456 ID number: 999000666 DOB: 01/01/1950 Gender: Female Insured: James Smith, spouse Address: 1111 Noname Court, Nowhere, NY 22222 Marital Status: Married Patient’s Employer: Homemaker Spouse’s Employer: U.S. Army Nature of Condition: Routine exam Patient Signature
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