HCFA-1500 Box 17 - Name of Referring Provider or Other Source

On the HCFA-1500 form, Box 17 is used to report the name of the referring, ordering, or supervising provider associated with the services rendered. This box supports various qualifiers, which are entered to the left of the vertical line, with the provider's name entered to the right.

Tip: Use the appropriate qualifier in the shaded portion of the field:

• DN – Referring Provider
• DK – Ordering Provider
• DQ – Supervising Provider

In our example below, we used 'DN' as the qualifier and entered 'John Smith MD' as the referring provider’s name.

In the X12 837 transaction, the information from Box 17 is represented by the NM1 segment in one of the following loops, based on the provider role:

• 2310A – Referring Provider (Qualifier: DN)
• 2420E – Ordering Provider (Qualifier: DK)
• 2310D – Supervising Provider (Qualifier: DQ)

Key X12 837 Details:
  • NM101: Entity Identifier Code (e.g., DN)
  • NM102: Entity Type Qualifier (1 for person)
  • NM103–NM105: Last Name, First Name, Middle Name
  • NM108: ID Qualifier (e.g., XX for NPI)
  • NM109: Provider Identifier (e.g., NPI)

Sample 837P (5010/4010) – 2310A Referring Provider

Note: Populate Box 17 with the correct qualifier and name. In the X12 837 electronic claim, this data appears in different loops depending on the provider’s role: Referring (2310A), Ordering (2420E), or Supervising (2310D).

Important: Additional rules may apply for Box 17 depending on the health plan and provider type. Always consult the official X12 implementation guides and payer-specific companion guides for complete instructions and compliance requirements.

For additional information on the X12 837 standard, please refer to the official implementation guides published by X12.

HCFA-1500 Form Box Locations

• HCFA-1500 Box 0 - Carrier Block
• HCFA-1500 Box 1 - Insurance Type
• HCFA-1500 Box 1a - Insured's ID Number
• HCFA-1500 Box 2 - Patient's Name
• HCFA-1500 Box 3 - Patient's Birth Date and Sex
• HCFA-1500 Box 4 - Insured's Name
• HCFA-1500 Box 5 - Patient's Address
• HCFA-1500 Box 6 - Patient Relationship to Insured
• HCFA-1500 Box 7 - Insured's Address
• HCFA-1500 Box 8 - Reserved For NUCC Use
• HCFA-1500 Box 9 - Other Insured's Name
• HCFA-1500 Box 9a - Other Insured's Policy or Group Number
• HCFA-1500 Box 9b - Reserved For NUCC Use
• HCFA-1500 Box 9c - Reserved For NUCC Use
• HCFA-1500 Box 9d - Insurance Plan Name or Program Name
• HCFA-1500 Box 10 - Is Patient's Condition Related To
• HCFA-1500 Box 10d - Claim Codes
• HCFA-1500 Box 11 - Insured's Policy Group or FECA Number
• HCFA-1500 Box 11a - Insured's Date of Birth and Sex
• HCFA-1500 Box 11b - Other Claim ID
• HCFA-1500 Box 11c - Insurance Plan Name or Program Name
• HCFA-1500 Box 11d - Is There Another Health Plan
• HCFA-1500 Box 12 - Patient's or Authorized Person's Signature
• HCFA-1500 Box 13 - Insured's or Authorized Person's Signature
• HCFA-1500 Box 14 - Date of Current Illness, Injury, Pregnancy (LMP)
• HCFA-1500 Box 15 - Other Date
• HCFA-1500 Box 16 - Dates Patient Unable to Work in Current Occupation
• HCFA-1500 Box 17 - Name of Referring Provider or Other Source [You are Here]
• HCFA-1500 Box 17a - Other ID
• HCFA-1500 Box 17b - NPI
• HCFA-1500 Box 18 - Hospitalization Dates Related to Current Services
• HCFA-1500 Box 19 - Additional Claim Information
• HCFA-1500 Box 20 - Outside Lab Charges

Grab a sample of the HCFA-1500 claim form here - HCFA 02/12 Claim Form