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Va cms 1500 Form: What You Should Know

See Exhibit A for current examples of forms CMS-1500 is  used for.) (Note: If the Medicare agency does not provide a copy of your Social Security Number, you  do not have to submit the SSN or Medicare Benefits. If the Medicare agency provides a Social Security Number,  you will be required to submit the SSN and Medicare Benefits.) All claims for services provided under the Medicare  program must include these information items by the due date shown on the form with regard to any Medicare benefit to which this form applies: (a) A copy of the SSN or Medicare benefits (b) The patient's Social Security Number (c) The date of birth, or if a Medicare Supplement to Medicare Form,  the date the patient's Medicare benefits become payable (d) The physician's name and title (e) The physician's office mailing address (f) The physician's  address of practice (g) A statement in block font that the information provided is complete and correct on the  part of the form provided and that the information is complete and correct as of the effective date of the form  (h) Optional information for which the individual is authorized to provide the required notice or other information to the  provider.

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