HCFA-1500 Box 2 - Patient's Name

On the HCFA-1500 form, box 2 is designated for the patient's name (Last, First, Middle). This is the patient who the services were rendered to for the claim. The name should be entered exactly as it appears on the patient's member card.

In our example below, we populated box 2 with the name 'Smith, John'. The name should be in the order of (Last, First, Middle) and use a comma to separate the Last and First Names.

Note: Follow the name order if there is one designated on the form, otherwise follow general naming order conventions. You want to keep the order consistent on every claim to ensure name translation mapping is successful.

So far, we talked about what the patient's name box on the HCFA form is and the information used to populate this location. In the next section, we'll briefly discuss the patient's name box in relation to the X12 837 format.

In the X12 837 format, the patient's name box information goes in the 2010CA Patient Name Loop - NM1 segment. More specifically, the HCFA Box 2 patient's name data goes in the NM103, NM104, NM105 and NM107 segment/data elements. If the patient is the same person as the subscriber, then you would only send that information in the 2010BA Subscriber loop and not in the 2010CA Patient Loop.

The example below shows the 2010CA Patient Name Loop and the 2010BA Subscriber Name Loop - NM1 segment. Remember that you only send the 2010CA Patient Name Loop if the patient is not the same person as the subscriber.

Please refer to the HCFA box 4 Insured's Name article for more details on the 2010CA - Subscriber Name Loop.

For additional information on the X12 837 format, we strongly recommend consulting the official X12 materials.

Note: When the Patient (box 2) and Insured (box 4) are the same person, send only the 2010BA Subscriber Name Loop with box 2. When they are different, populate the 2010BA Subscriber Name Loop with box 4 and 2010CA Patient Name Loop with box 2.

Sample 837P (5010) - 2010CA - Patient Name

Sample 837P (5010) - 2010BA - Subscriber Name

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 [You are Here]
• 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
• 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
• HCFA-1500 Box 21 - Diagnosis or Nature of Illness or Injury
• HCFA-1500 Box 22 - Resubmission Code and Original Reference Number
• HCFA-1500 Box 23 - Prior Authorization Number
• HCFA-1500 Box 24a - Date(s) of Service
• HCFA-1500 Box 24b - Place of Service
• HCFA-1500 Box 24c - EMG
• HCFA-1500 Box 24d - Procedures, Services, or Supplies
• HCFA-1500 Box 24e - Diagnosis Pointer
• HCFA-1500 Box 24f - Charges
• HCFA-1500 Box 24g - Days or Units
• HCFA-1500 Box 24h - EPSDT/Family Plan
• HCFA-1500 Box 24i - Rendering Provider ID Qualifier
• HCFA-1500 Box 24j - Rendering Provider ID
• HCFA-1500 Box 25 - Federal Tax ID Number
• HCFA-1500 Box 26 - Patient's Account No.
• HCFA-1500 Box 27 - Accept Assignment
• HCFA-1500 Box 28 - Total Charge
• HCFA-1500 Box 29 - Amount Paid
• HCFA-1500 Box 30 - Rsvd for NUCC Use
• HCFA-1500 Box 31 - Signature of Physician or Supplier Including Degrees or Credentials
• HCFA-1500 Box 32 - Service Facility Location Information

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