Claim Forms and Instructions

CMS-1500 (02/12) Health Insurance Claim Form

• CMS-1500 Claim Form Instructions
• CMS-1500 (02/12) Sample Claim Form

UB04 Health Insurance Claim Form

• UB04 Claim Form Instructions
• UB04 Sample Claim Form

ADA 2012 Health Insurance Claim Form
(use new claim form now)

• ADA 2012 Claim Form Instructions
• ADA 2012 Sample Claim Form

ADA 2006 Health Insurance Claim Form
(as of January 1, 2016 this is no longer an acceptable form please use ADA 2012 Health Insurance Claim Form going forward)

• ADA 2006 Claim Form Instructions
• ADA 2006 Sample Claim Form

Targeted Medical Care Health Insurance Claim Form

• Targeted Medical Care 470-2486 Claim Form Instructions
• 470-2486 Claim Form

Crossover Health Insurance Claim Form

• Institutional Crossover Claim Form Instructions
• Institutional Crossover Forms (When using Google Chrome, this form will not open on your screen. Even if it does not open, save this file to your hard drive. Once saved on your hard drive, the saved file WILL OPEN from your hard drive.)
• Professional Crossover Claim Form Instructions
• Professional Crossover Forms (When using Google Chrome, this form will not open on your screen. Even if it does not open, save this file to your hard drive. Once saved on your hard drive, the saved file WILL OPEN from your hard drive.)
• Crossover Tips Avoiding Returned Claims