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APPROVED OMB-0938-0999 FORM CMS-1500 (08-05). Page 2. BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS Page 1. PLEASE PRINT OR TYPE. APPROVED OMB-0938-1197 FORM 1500 (02-12)BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BY. APPLICABLE PROGRAMS. NOTICE: Any person who The Center of Medicaid and Medicare Services (CMS) form 1500 must be used to bill SFHP for medical services. discharged, leave the discharge date blank. CMS 1500. Form Title. Health Insurance Claim Form. Revision Date. 2012-02-01. O.M.B. #. 0938-1197. O.M.B. Expiration Date. 2023-10-31. CMS Manual. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT'S OR AUTHORIZED PERSON'S FORM HCFA-1500 (12-90), FORM RRB-1500,. FORM OWCP-1500. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other HEALTH INSURANCE CLAIM FORM. APPROVED BY NATIONAL UNIFOAM CLAIM COMMITTEE {NUCC) 02/12. ITT PICA. 11. MEDICARE MEDICAID TAICARE. CHAMPVA GROUP.

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