CMS-1500 CLM-02007

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CMS-1500 — CLM-02007

HEALTH INSURANCE CLAIM FORM — CMS-1500 (facsimile)
CLM-02007
1 Payer
Self-pay
1a Insured ID
2 Patient name
Smith, Peter
3 DOB
Jan 3, 2000
5 Address
,
21 Diagnosis (ICD-10)
—
23 Prior Auth
—
24. Service lines
24A Date
Jul 1, 2026
B POS
12
D HCPCS
E0250
Mod
RR
E Dx
A
F Charges
$165.00
G Units
1
28 Total charge
$165.00
33 Billing provider
Lakeview Medical Supply · NPI 1980000000
Readable facsimile for demo. Production renders the official red-ink form / 837P EDI.