HCFA-1500 Form Guide – One of the Most Comprehensive Box-by-Box References

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September 02, 2025

This is one of the most comprehensive HCFA-1500 guides available online. We provide in-depth explanations for all 33 boxes on the form, detailing the required data, how each field maps to the X12 837P 5010 electronic claim format, and illustrating the process with real-world examples. Whether you are a provider, biller, or coder, this guide offers everything you need in one place to handle both paper and electronic claim submission with confidence.

Tip: Use this guide alongside payer-specific companion guides to ensure compliance. While the HCFA-1500 provides the paper claim layout, the 837P is required for electronic submission.

Quick Example – Box 1a (Insured’s ID Number)

On the HCFA-1500 form, Box 1a is used to report the Insured’s ID Number. This is the unique policy or subscriber number from the patient’s insurance card.

In our example, the insured’s ID number is ABC12345678.

HCFA-1500 Box 1a - Insured's ID Number

In the X12 837P 5010 transaction, Box 1a maps to the 2010BA Subscriber Loop:

  • NM109 – Insured’s ID Number (e.g., ABC12345678)

Sample 837P (5010) – Box 1a Mapping

> Subscriber Information (2010BA) NM1*IL*1*DOE*JOHN****MI*ABC12345678~

Note: The insured’s ID in Box 1a must exactly match the number on the member’s card. Any mismatch can result in claim rejection or denial.

HCFA-1500 Box Interactive Form

The HCFA-1500 image below is interactive—hover or focus to highlight a box, then click (or press Enter/Space) to open its detailed guide. All hotspots are keyboard-accessible.

HCFA-1500 Claim Form Box 0 - Carrier Block Box 1 - Insurance Type Box 1a - Insured's ID Number Box 2 - Patient's Name Box 3 - Patient's Birth Date and Sex Box 4 - Insured's Name Box 5 - Patient's Address Box 6 - Patient Relationship to Insured Box 7 - Insured's Address Box 8 - Reserved For NUCC Use Box 9 - Other Insured's Name Box 9a - Other Insured's Policy or Group Box 9b - Reserved For NUCC Use Box 9c - Reserved For NUCC Use Box 9d - Insurance Plan Name or Program Name Box 10 - Is Patient's Condition Related To Box 10d - Claim Codes Box 11 - Insured's Policy Group or FECA Number Box 11a - Insured's Date of Birth and Sex Box 11b - Other Claim ID Box 11c - Insurance Plan Name or Program Name Box 11d - Is There Another Health Plan Box 12 - Patient's or Authorized Person's Signature Box 13 - Insured's or Authorized Person's Signature Box 14 - Date of Current Illness, Injury, Pregnancy (LMP) Box 15 - Other Date Box 16 - Dates Patient Unable to Work in Current Occupation Box 17 - Name of Referring Provider or Other Source Box 17a - Other ID Box 17b - NPI Box 18 - Hospitalization Dates Related to Current Services Box 19 - Additional Claim Information Box 20 - Outside Lab Charges Box 21 - Diagnosis or Nature of Illness or Injury Box 22 - Resubmission Code and Original Reference Number Box 23 - Prior Authorization Number Box 24a - Date(s) of Service Box 24b - Place of Service Box 24c - EMG Box 24d - Procedures, Services, or Supplies Box 24e - Diagnosis Pointer Box 24f - Charges Box 24g - Days or Units Box 24h - EPSDT/Family Plan Box 24i - Rendering Provider ID Qualifier Box 24j - Rendering Provider ID Box 25 - Federal Tax ID Number Box 26 - Patient's Account No. Box 27 - Accept Assignment Box 28 - Total Charge Box 29 - Amount Paid Box 30 - Rsvd for NUCC Use Box 31 - Signature of Physician or Supplier Including Degrees or Credentials Box 32 - Service Facility Location Information Box 32a - NPI Box 32b - Other ID Box 33 - Billing Provider Info & Phone No Box 33a - NPI Box 33b - Other ID

HCFA-1500 Box List

This index links to every box-specific article in our library. Each article provides detailed explanations, payer notes, and X12 837P 5010 mapping with code samples. Click a link below to jump directly to a specific HCFA-1500 box:

Box Field Name Link
0Carrier BlockView
1Insurance TypeView
1aInsured's ID NumberView
2Patient's NameView
3Patient's Birth Date and SexView
4Insured's NameView
5Patient's AddressView
6Patient Relationship to InsuredView
7Insured's AddressView
8Reserved For NUCC UseView
9Other Insured's NameView
9aOther Insured's Policy or Group NumberView
9bReserved For NUCC UseView
9cReserved For NUCC UseView
9dInsurance Plan Name or Program NameView
10Is Patient's Condition Related ToView
10dClaim CodesView
11Insured's Policy Group or FECA NumberView
11aInsured's Date of Birth and SexView
11bOther Claim IDView
11cInsurance Plan Name or Program NameView
11dIs There Another Health PlanView
12Patient's or Authorized Person's SignatureView
13Insured's or Authorized Person's SignatureView
14Date of Current Illness, Injury, Pregnancy (LMP)View
15Other DateView
16Dates Patient Unable to Work in Current OccupationView
17Name of Referring Provider or Other SourceView
17aOther IDView
17bNPIView
18Hospitalization Dates Related to Current ServicesView
19Additional Claim InformationView
20Outside Lab ChargesView
21Diagnosis or Nature of Illness or InjuryView
22Resubmission Code and Original Reference NumberView
23Prior Authorization NumberView
24aDate(s) of ServiceView
24bPlace of ServiceView
24cEMGView
24dProcedures, Services, or SuppliesView
24eDiagnosis PointerView
24fChargesView
24gDays or UnitsView
24hEPSDT/Family PlanView
24iRendering Provider ID QualifierView
24jRendering Provider IDView
25Federal Tax ID NumberView
26Patient's Account No.View
27Accept AssignmentView
28Total ChargeView
29Amount PaidView
30Rsvd for NUCC UseView
31Signature of Physician or Supplier Including Degrees or CredentialsView
32Service Facility Location InformationView
32aNPIView
32bOther IDView
33Billing Provider Info & Phone NoView
33aNPIView
33bOther IDView

Final Note: With every HCFA-1500 box explained and mapped to the X12 837P 5010, this guide serves as one of the most complete resources available for professional claim submission. While other references may only provide high-level notes, this guide goes further with full mapping and real code samples, giving providers, billers, and coders a reliable one-stop resource to streamline both paper and electronic claims.

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