HCFA-1500 Box 5 - Patient's Address

On the HCFA-1500 form, box 5 is designated for the patient's street address, city, state, zip code and telephone number. This is the patient who the services were rendered to on the claim.

In our example below, we populated box 5 with the street address'123 Main Street', city 'Anytown', state 'NE', zip code '12345' and the telephone number '415-555-0132'.

Note: The full 9-digit zip code is optional and only the 5-digit zip code is required. If the last 4-digits of the full 9-digit zip code are unknown, it's often acceptable to use 0000 or 9999. Example: 12345-0000

So far, we talked about what the patient's address 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 address box in relation to the X12 837 format.

In the X12 837 format, the patient's address box information goes in the 2010CA Patient Name Loop - N3/N4 segments. More specifically, the HCFA box 5 patient's address data goes in the N301, N401, N402 and N403 segment/data elements.

The 2010CA Patient Name Loop is only sent when the patient and subscriber are NOT the same. If they are the same, then you would populate the 2010BA Subscriber Name Loop - N3/N4 segments. You can pull the data from patient box as it's common for the subscriber info to be blank when the patient is the subscriber.

The example below shows the 2010CA Patient Name Loop for both the 5010/4010 format - N3/N4 segments. Remember that you only send the 2010CA Patient Name Loop if the patient is NOT the same person as the subscriber.

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

Note: There is no 837 location for the patient telephone number.

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

Sample 837P (4010) - 2010CA - Patient 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
• HCFA-1500 Box 3 - Patient's Birth Date and Sex
• HCFA-1500 Box 4 - Insured's Name
• HCFA-1500 Box 5 - Patient's Address [You are Here]
• 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