FORM LOCATORS FOR CMS-1500 FORM QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
ALREADY GRADED A+
Form Locator 1: Type of Insurance Ans✓✓✓Identifies what type of
insurance the patient carries.
List of governmental plans: Medicare, Medicaid,
TRICARE/CHAMPUS, CHAMPVA, and FECA Black Lung.
2 other options: Group Health Plan and other.
Form Locator 1a: Insured's I.D. Number Ans✓✓✓Asks for the insured's
insurance I.D. Number as reflected on the insurance card.
Form Locator 2: Patient's name Ans✓✓✓Enter the name of the patient
who received services. This information is input as full last name, first
name and middle name or initial. If patient's name is the same as the
insured's name, then it is not necessary to report the patient's name.
Form Locator 3: Patient's Date of Birth/Gender Ans✓✓✓Enter the
patient's date of birth and gender. The date of birth is entered using the
eight-digit format: MMDDYYYY.
Form Locator 4: Insured's Name Ans✓✓✓Name of person who is
insured. If patient is the insured, the word "same" should be entered. Use
commas to separate last name, first name, and middle initial. If Medicare
is primary, leave the field blank.
, Form Locator 5: Patient's Address Ans✓✓✓Enter the patient's home
address and telephone number. Taken from the patient information form.
Address should include the street name and number, city, state (two-
letter abbreviation), and zip code. Do not use commas, periods, or other
symbols in address. When entering a nine-digit code, include the
hyphen. Do not use a hyphen or space as a separator within the phone
number. If patient's address is the same as insured's address, then it is
not necessary to report the patient's address.
Form Locator 6: Patient's Relationship to the Insured Ans✓✓✓Enter an
X in the correct box to indicate the patient's relationship to the insured.
Options: Self, Spouse, Child, or Other.
Form Locator 7: Insured's Address Ans✓✓✓Enter Insured's address.
First line is for the street address; the second line, the city and state; the
third line, the ZIP code.
Form Locator 8: Reserved for NUCC Use Ans✓✓✓This field was
previously used to report "Patient Status". "Patient Status" does not exist
in 5010A1, so this field has been eliminated.
Form Locator 9: Other Insured's Name Ans✓✓✓If item 11d is marked,
complete fields 9, 9a, and 9d; otherwise, leave blank. When additional
group health coverage exists, enter other insured's full last name, first
name, and middle initial of the enrollee in another health plan if it is
different from that shown in Item Number 2. If no secondary policy;
leave blank.
CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
ALREADY GRADED A+
Form Locator 1: Type of Insurance Ans✓✓✓Identifies what type of
insurance the patient carries.
List of governmental plans: Medicare, Medicaid,
TRICARE/CHAMPUS, CHAMPVA, and FECA Black Lung.
2 other options: Group Health Plan and other.
Form Locator 1a: Insured's I.D. Number Ans✓✓✓Asks for the insured's
insurance I.D. Number as reflected on the insurance card.
Form Locator 2: Patient's name Ans✓✓✓Enter the name of the patient
who received services. This information is input as full last name, first
name and middle name or initial. If patient's name is the same as the
insured's name, then it is not necessary to report the patient's name.
Form Locator 3: Patient's Date of Birth/Gender Ans✓✓✓Enter the
patient's date of birth and gender. The date of birth is entered using the
eight-digit format: MMDDYYYY.
Form Locator 4: Insured's Name Ans✓✓✓Name of person who is
insured. If patient is the insured, the word "same" should be entered. Use
commas to separate last name, first name, and middle initial. If Medicare
is primary, leave the field blank.
, Form Locator 5: Patient's Address Ans✓✓✓Enter the patient's home
address and telephone number. Taken from the patient information form.
Address should include the street name and number, city, state (two-
letter abbreviation), and zip code. Do not use commas, periods, or other
symbols in address. When entering a nine-digit code, include the
hyphen. Do not use a hyphen or space as a separator within the phone
number. If patient's address is the same as insured's address, then it is
not necessary to report the patient's address.
Form Locator 6: Patient's Relationship to the Insured Ans✓✓✓Enter an
X in the correct box to indicate the patient's relationship to the insured.
Options: Self, Spouse, Child, or Other.
Form Locator 7: Insured's Address Ans✓✓✓Enter Insured's address.
First line is for the street address; the second line, the city and state; the
third line, the ZIP code.
Form Locator 8: Reserved for NUCC Use Ans✓✓✓This field was
previously used to report "Patient Status". "Patient Status" does not exist
in 5010A1, so this field has been eliminated.
Form Locator 9: Other Insured's Name Ans✓✓✓If item 11d is marked,
complete fields 9, 9a, and 9d; otherwise, leave blank. When additional
group health coverage exists, enter other insured's full last name, first
name, and middle initial of the enrollee in another health plan if it is
different from that shown in Item Number 2. If no secondary policy;
leave blank.
