CMS-1500 CLM-02001

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CMS-1500 — CLM-02001

HEALTH INSURANCE CLAIM FORM — CMS-1500 (facsimile)
CLM-02001
1 Payer
Medicare (Railroad/Part B)
1a Insured ID
4M81-RR-552
2 Patient name
Ellis, Margaret
3 DOB
Sep 3, 1944
5 Address
17 Lakeview Terrace, Dallas TX
21 Diagnosis (ICD-10)
J96.11 J44.9
23 Prior Auth
—
24. Service lines
24A Date
Jun 15, 2026
B POS
12
D HCPCS
E1390
Mod
RR
E Dx
A
F Charges
$178.00
G Units
1
28 Total charge
$178.00
33 Billing provider
Lakeview Medical Supply · NPI 1980000000
Readable facsimile for demo. Production renders the official red-ink form / 837P EDI.