Claim Forms and Instructions

Important Information Regarding Claims Forms

The claims forms provided on this website are for reference purposes only. In order to process claims, IME must have original versions of the forms. Please do not submit claims on the forms found on this website. Original versions of the CMS-1500, UB-04 and Dental Claim forms can be found at office supply stores. Originals of the Targeted Medical Care claim forms can be requested from IME by contacting Provider Services at 1-800-338-7909 or locally at 515-256-4609.

Health Insurance Claim Form Instructions and Sample Forms

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

UB04 Health Insurance Claim Form

UB04 Claim Form Instructions [3]
UB04 Sample Claim Form [4]

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

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

Crossover Health Insurance Claim Form

Institutional Crossover Claim Form Instructions [9]
Institutional Crossover Forms [10] (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 [11]
Professional Crossover Forms [12] (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 [13]

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