CMS Pub. 100-04, ch. 26, § 30

The National Uniform Claims Committee (NUCC) has approved the printing standards

for Form CMS-1500 (08-05) paper claim. These standards are as follows:

The Form CMS-1500 (08-05) is designed to accommodate 10-pitch Pica type, 6 lines per

inch vertical and 10 characters per inch (cpi) horizontal. Once adjusted to the left and

right, PICA Alignment blocks in the first print line and characters appear within form

lines as shown in the print file matrix.

Also provided on the Form CMS-1500 (08-05) is a position bar. This is a thick

horizontal line that is at the base of the PICA alignment Boxes.

The Form CMS-1500 (08-05) is used in four different styles. Any one of these four

styles may be printed from two negatives in concurrence with the layout that was

approved by the NUCC. The face/back negative furnished must be used for all parts.

Compliance with these standards is required to facilitate the use of image processing

technology such as Optical Character Recognition (OCR), facsimile transmission, and

image storing.

Cut Sheet:

Size - 8.5 by 11 inches (plus or minus .0625 inch) or 217mm by 279mm (plus or minus

2mm).

Print - Face and back, head to head.

Margins -

Face - The top margin from the top edge of the form to the first print position is 1.33

inches or 34mm. The left margin is 0.3 inches to the left end of the first print position.

Back - 0.25 inch head and foot, 0.25 inch left and right or 6.35 mm head and foot, 6.35

mm left and right.

Offset - The X and Y offset for margins must not vary by more than +/-0.1 inch or 2.54

mm from sheet to sheet.

The X offset refers to the horizontal distance from the left edge of the paper to the

beginning of the printing. The Y offset refers to the vertical distance between the top of

the paper and the beginning of the printing.

Askewity - The askewity of the printed image must be no greater than 0.15mm in

100mm.

Paper Stock - Basis weight 20# recycled 30% postconsumer waste, White Environmental

Paper Alliance (EPA) or approved paper stock. Smoothness: FS to be (140-160), or

equivalent stock.

Ink color -

Face - (OCR-Red Ink) must be in Flint J-6983 Red OCR “dropout” ink or an exact

match, formerly known as Sinclair Valentine). There is to be no contamination with

“Black” ink or pigment. Printer must maintain proper ink reflections limits of the OCR

reader specified by the purchaser.

Back - Same as face.

Titles - Color of any titles if applicable: Are to be in the same ink as the form, Flint

J6983 OCR Red “dropout” ink.

Symbol - The identifiable 1500 in a rectangle located in the upper left front of the form

above the PICA boxes is to be in black ink.

Two Part Snap-set:

Size - Dimensions are same as Cut Sheet (detached 8.5 by 11 inches), plus top stub (.5 to

.75 inches).

Print -

Part 1 - Face and back - head to head.

Part 2 - Face and back - head to head.

Margins - Same as Cut Sheet.

Askewity - Same as Cut Sheet.

Stock -

Part 1 - Carbonless, 20 CB - Recycled White

Part 2 - Any color that will not interfere with scanning of Part 1 sheet.

Ink Color -

Part 1 - (OCR-Red Ink) must be in Flint J-6983 Red OCR “dropout” ink or an exact

match.

Part 2 - Any color that will not interfere with scanning of Part 1 sheet.

Titles - Color of any titles if applicable: Are to be in the same ink as the form, Flint

J6983 OCR Red “dropout” ink.

Symbol - The identifiable 1500 in a rectangle located in the upper left front of the form

above the PICA boxes is to be in black ink.

Perforations - Perforate top stub for disassembly of parts.

One Part Marginally Punched Continuous Form:

Size - Same dimensions as for Cut Sheet, plus 0.5 inch left and right, (overall: 9.5 by 11

inches, detached: 8.5 by 11 inches).

Print - Face and back, head to head.

Margins - On detached sheet, same as for Cut Sheet.

Askewity - On detached sheet, same as for Cut Sheet.

Paper Stock - Same as for Cut Sheet.

Ink Color - Same as for Cut Sheet (OCR-Red Ink) must be in Flint J-6983 Red OCR

“dropout” ink or an exact match.

Titles - Color of any titles if applicable: Are to be in the same ink as the form, Flint J6983

OCR Red “dropout” ink.

Symbol - The identifiable 1500 in a rectangle located in the upper left front of the form

above the PICA boxes is to be in black ink.

Perforations - Marginally 0.5 inch left and right, tear line horizontally every 11 inches.

Two Part Marginally Punched Continuous Forms:

Size - Same dimensions as for Cut Sheet, plus 0.5 inch left and right, (overall: 9.5 by 11

inches, detached: 8.5 by 11 inches).

Print -

Part 1 -Face and back, head to head.

Part 2 -Face and back, head to head.

Margins - On detached sheet, same as for Cut Sheet.

Askewity - On detached sheet, same as for Cut Sheet.

Paper Stock -

Part 1 - Carbonless, 20 CB - Recycled White

Part 2 - Any color or weight that does not interfere with scanning of part 1 sheet. Suggest

the following sequence:

Paper Weight:

1st part is 20 CB - OCR Bond

2nd part is 14 CFB (if not last part)

Last part is 15CF

CB = Coated Back (Carbonless black print)

CFB = Coated Front and Back (Carbonless black print)

CF = Coated Front (Carbonless black print)

Ink color -

Part 1 - Same as for cut sheet, (OCR-Red Ink) must be in Flint J-6983 Red OCR

“dropout” ink or an exact match.

Part 2 - Any color that will not interfere with scanning of the part 1 sheet.

Titles - Color of any titles if applicable: Are to be in the same ink as the form, Flint J6983

OCR Red “dropout” ink.

Symbol - The identifiable 1500 in a rectangle located in the upper left front of the form

above the PICA boxes is to be in black ink.

Joining - Crimp left and right.

Perforations - Marginally 0.5 inch left and right, tear line horizontally every 11”.

NOTE: Users may determine the number of parts that are applicable to their needs. Up

to four total parts are feasible on some printers; some other printers may limit the

readability of multiple plies. Color of any titles if applicable: Are to be in the same ink

as the form, Flint J6983 OCR Red “dropout” ink.

Symbol: NUCC requires the use of an approved Form CMS-1500 in the formats

provided displaying the 1500 symbol as approved by the NUCC. All printing of Form

CMS-1500 must occur in accordance with the NUCC requirements.

Form Name - CMS-1500 Health Insurance Paper Claim Form, Approved by the National

Uniform Claims Committee (NUCC).

Form Identification: The lower right-hand margin contains the approved OMB numbers

and should be consistent throughout.

No modification is to be made to the Form CMS-1500 (08-05) without prior approval

from the NUCC and CMS.

Exhibit 1

(Rev. 1970, 05-21-10)

Form CMS-1500 (08/05) User Print File Specifications (Formerly Exhibit 2)

LINE FIELD LITERAL

FIELD

TYPE* BYTES

COLUMNS

1 Left printer alignment block M 3 01-03

1 Right printer alignment block M 3 77-79

3 1 Medicare M 1 01

3 1 Medicaid M 1 08

3 1 Tricare Champus M 1 15

3 1 Champva M 1 24

3 1 Group Health Plan M 1 31

3 1 FECA Blk Lung M 1 39

3 1 Other M 1 45

3 1a Insured's ID Number A/N 29 50-78

5 2 Patient's Name (Last, First, MI) A 28 01-28

5 3 Patient's Birth Date (Month) N 2 31-32

5 3 Patient's Birth Date (Day) N 2 34-35

5 3 Patient's Birth (Year) N 4 37-40

5 3 Sex-Male M 1 42

5 3 Sex-Female M 1 47

5 4 Insured Name (Last, First, MI) A 29 50-78

7 5 Patient's Address A/N 28 01-28

7 6 Patient Relationship to Insured (Self) M 1 33

7 6 Patient Relationship to Insured (Spouse) M 1 38

7 6 Patient Relationship to Insured (Child) M 1 42

7 6 Patient Relationship to Insured (Other) M 1 47

7 7 Insured's Address A/N 29 50-78

9 5 Patient's City A 24 01-24

* M = mark (X), A = alpha, N = numeric

9 5 Patient's State A 3 26-28

9 8 Patient Status (Single) M 1 35

LINE FIELD LITERAL

FIELD

TYPE* BYTES

COLUMNS

9 8 Patient Status (Married) M 1 41

9 8 Patient Status (Other) M 1 47

9 7 Insured's City A 23 50-72

9 7 Insured's State A 4 74-77

11 5 Patient's ZIP Code N 12 01-12

11 5 Patient's Area Code N 3 15-17

11 5 Patient's Phone Number N 10 19-28

11 8 Patient Status (Employed) M 1 35

11 8 Patient Status (Full Time Student) M 1 41

11 8 Patient Status (Part Time Student) M 1 47

11 7 Insured's ZIP Code N 12 50-61

11 7 Insured's Area Code N 3 65-67

11 7 Insured's Phone Number N 10 69-78

13 9 Other Insured's Name (Last, First, MI) A 28 01-28

13 11 Insured's Policy, Group or FECA

Number

A/N 29 50-78

15 9a Other Insured's Policy or Group

Number

A/N 28 01-28

15 10a Condition Related (Employment C/P,

Yes)

M 1 35

15 10a Condition Related (Employment C/P,

No)

M 1 41

15 11a Insured's Date of Birth (Month) N 2 53-54

15 11a Insured's Date of Birth (Day) N 2 56-57

15 11a Insured's Date of Birth (Year) N 4 59-62

15 11a Sex-Male M 1 68

15 11a Sex-Female M 1 75

17 9b Other Insured's Date of Birth (Month) N 2 02-03

* M = mark (X), A = alpha, N = numeric

17 9b Other Insured's Date of Birth (Day) N 2 05-06

17 9b Other Insured's Date of Birth (Year) N 4 08-11

LINE FIELD LITERAL

FIELD

TYPE* BYTES

COLUMNS

17 9b Sex-Male M 1 18

17 9b Sex-Female M 1 24

17 10b Condition Related To: (Auto Accident-

Yes)

M 1 35

17 10b Condition Related To: (Auto Accident-

No)

M 1 41

17 10b Condition Related To: (Auto Accident-

State)

A 2 45-46

17 11b Insured's Employer's Name or School

Name

A/N 29 50-78

19 9c Other Insured's Employer's Name or

School

A/N 28 01-28

19 10c Other Accident (Yes) M 1 35

19 10c Other Accident (No) M 1 41

19 11c Insured's Insurance Plan or PayerID A/N 29 50-78

21 9d Other Insured’s Plan Name or Payer

ID

A/N 28 01-28

21 10d (Reserved for Local Use) A/N 19 30-48

21 11d Another Benefit Health Plan (Yes) M 1 52

21 11d Another Benefit Health Plan (No) M 1 57

25 12 Left Blank for Patient's Signature & Date

25 13 Left Blank for Insured's Signature

27 14 Date of Current Illness, Injury,

Pregnancy (Month)

N 2 02-03

27 14 Date of Current Illness, Injury,

Pregnancy (Day)

N 2 05-06

27 14 Date of Current Illness, Injury,

Pregnancy - (Year)

N 4 08-11

27 15 First Date Has Had Same or Similar

Illness (Month)

N 2 37-38

* M = mark (X), A = alpha, N = numeric

27 15 First Date Has Had Same or Similar

Illness (Day)

N 2 40-41

27 15 First Date Has Had Same or Similar

Illness - (Year)

N 4 43-46

LINE FIELD LITERAL

FIELD

TYPE* BYTES

COLUMNS

27 16 Dates Patient Unable to Work (From

Month)

N 2 54-55

27 16 Dates Patient Unable to Work (From

Day)

N 2 57-58

27 16 Dates Patient Unable to Work (From

Year)

N 4 60-63

27 16 Dates Patient Unable to Work (To

Month)

N 2 68-69

27 16 Dates Patient Unable to Work (To Day)

N 2 71-72

27 16 Dates Patient Unable to Work (To

Year)

N 4 74-787

28 17a Legacy Qualifier/Provider Number of

Referring Physician

A/N 19 30-48

29 17 Name of Referring Physician or Other

Source

A 26 01-26

29 17b NPI Number of Referring Physician N 17 32-48

29 18 Hospitalization Related Current Svcs

(From Month)

N 2 54-55

29 18 Hospitalization Related Current Svcs

(From Day)

N 2 57-58

29 18 Hospitalization Related Current Svcs

(From Year)

N 4 60-63

29 18 Hospitalization Related Current Svcs

(To Month)

N 2 68-69

29 18 Hospitalization Related Current Svcs

(To Day)

N 2 71-72

29 18 Hospitalization Related Current Svcs

(To Year)

N

30 19 Reserved for Local Use A/N 35 14-48

31 19 Reserved for Local Use A/N 48 01-48

31 20 Outside Lab (Yes) M 1 52

* M = mark (X), A = alpha, N = numeric

31 20 Outside Lab (No) M 1 57

31 20 $ Charges N 8/8 62-78

LINE FIELD LITERAL

FIELD

TYPE* BYTES

COLUMNS

33 21.1 Diagnosis or Nature of Illness or Injury

(Code)

A/N 8 03-10

33 21.3 Diagnosis or Nature of Illness or Injury

(Code)

A/N 8 30-37

33 22 Medicaid Resubmission Code A/N 11 50-60

33 22.2 Original Reference Number A/N 18 61-78

35 21.2 Diagnosis or Nature of Illness or Injury

(Code)

A/N 8 03-10

35 21.4 Diagnosis or Nature of Illness or Injury

(Code)

A/N 8 30-37

35 23 Prior Authorization Number A/N 29 50-78

38 24 Line Detail Narrative A/N 63 01-63

38 24.1i Legacy Qualifier Rendering Provider A/N 2 65-66

38 24.1j Legacy Provider Number Rendering

Provider

A/N 11 68-78

39 24.1a Date(s) of Service - (From Month) N 2 01-02

39 24.1a Date(s) of Service - (From Day) N 2 04-05

39 24.1a Date(s) of Service - (From Year) N 2 07-08

39 24.1a Date(s) of Service - (To Month) N 2 10-11

39 24.1a Date(s) of Service - (To Day) N 2 13-14

39 24.1a Date(s) of Service - (To Year) N 2 16-17

39 24.1b Place of Service A/N 2 19-20

39 24.1c EMG A 2 22-23

39 24.1d Procedures, Svcs or Supplies

(CPT/HCPCS)

A/N 6 25-30

39 24.1d Procedures, Svcs or Supplies (Modifier

1)

A/N 2 33-34

39 24.1d Procedures, Svcs or Supplies (Modifier

2)

A/N 2 36-37

39 24.1d Procedures, Svcs or Supplies (Modifier

3)

A/N 2 39-40

39 24.1d Procedures, Svcs or Supplies (Modifier

4)

A/N 2 42-43

* M = mark (X), A = alpha, N = numeric

39 24.1e Diagnosis Pointer N 4 45-48

39 24.1f $ Charges N 8 50-57

LINE FIELD LITERAL

FIELD

TYPE* BYTES

COLUMNS

39 24.1g Days or Units N 3 59-61

39 24.1h EPSDT Family Plan A 1 63

39 24.li Legacy Qualifier Rendering Provider

(Leave Blank)

A/N 0

39 24.1j Legacy Provider Number Rendering

Provider

A/N 11 68-78

40 24 Line Detail Narrative A/N 63 01-63

40 24.2i Legacy Qualifier Rendering Provider A/N 2 65-66

40 24.2j Legacy Provider Number Rendering

Provider

A/N 11 68-78

41 24.2a Date(s) of Service - (From Month) N 2 01-02

41 24.2a Date(s) of Service - (From Day) N 2 04-05

41 24.2a Date(s) of Service - (From Year) N 2 07-08

41 24.2a Date(s) of Service - (To Month) N 2 10-11

41 24.2a Date(s) of Service - (To Day) N 2 13-14

41 24.2a Date(s) of Service - (To Year) N 2 16-17

41 24.2b Place of Service A/N 2 19-20

41 24.2c EMG A 2 22-23

41 24.2d Procedures, Svcs or Supplies

(CPT/HCPCS)

A/N 6 25-30

41 24.2d Procedures, Svcs or Supplies (Modifier

1)

A/N 2 33-34

41 24.2d Procedures, Svcs or Supplies (Modifier

2)

A/N 2 36-37

41 24.2d Procedures, Svcs or Supplies (Modifier

3)

A/N 2 39-40

41 24.2d Procedures, Svcs or Supplies (Modifier

4)

A/N 2 42-43

41 24.2e Diagnosis Pointer N 4 45-48

41 24.2f $ Charges N 8 50-57

41 24.2g Days or Units N 3 59-61

41 24.2h EPSDT Family Plan A 1 63

* M = mark (X), A = alpha, N = numeric

41 24.2i Legacy Qualifier Rendering Provider

(Leave Blank)

A/N 0

LINE FIELD LITERAL

FIELD

TYPE* BYTES

COLUMNS

41 24.2j Legacy Provider Number Rendering

Provider

A/N 11 68-78

42 24 Line Detail Narrative A/N 63 01-63

42 24.3i Legacy Qualifier Rendering Provider A/N 2 65-66

42 24.3j Legacy Provider Number Rendering

Provider

A/N 11 68-78

43 24.3a Date(s) of Service - (From Month) N 2 01-02

43 24.3a Date(s) of Service - (From Day) N 2 04-05

43 24.3a Date(s) of Service - (From Year) N 2 07-08

43 24.3a Date(s) of Service - (To Month) N 2 10-11

43 24.3a Date(s) of Service - (To Day) N 2 13-14

43 24.3a Date(s) of Service - (To Year) N 2 16-17

43 24.3b Place of Service A/N 2 19-20

43 24.3c EMG A 2 22-23

43 24.3d Procedures, Svcs or Supplies

(CPT/HCPCS)

A/N 6 25-30

43 24.3d Procedures, Svcs or Supplies (Modifier

1)

A/N 2 33-34

43 24.3d Procedures, Svcs or Supplies (Modifier

2)

A/N 2 36-37

43 24.3d Procedures, Svcs or Supplies (Modifier

3)

A/N 2 39-40

43 24.3d Procedures, Svcs or Supplies (Modifier

4)

A/N 2 42-43

43 24.3e Diagnosis Pointer N 4 45-48

43 24.3f $ Charges N 8 50-57

43 24.3g Days or Units N 3 59-61

43 24.3h EPSDT Family Plan A 1 63

43 24.3i Legacy Qualifier Rendering Provider

(Leave Blank)

A/N 0

43 24.3j Legacy Provider Number Rendering

Provider

A/N 11 68-78

44 24 Line Detail Narrative A/N 63 01-63

* M = mark (X), A = alpha, N = numeric

44 24.4i Legacy Qualifier Rendering Provider A/N 2 65-66

LINE FIELD LITERAL

FIELD

TYPE* BYTES

COLUMNS

44 24.4j Legacy Provider Number Rendering

Provider

A/N 11 68-78

45 24.4a Date(s) of Service - (From Month) N 2 01-02

45 24.4a Date(s) of Service - (From Day) N 2 04-05

45 24.4a Date(s) of Service - (From Year) N 2 07-08

45 24.4a Date(s) of Service - (To Month) N 2 10-11

45 24.4a Date(s) of Service - (To Day) N 2 13-14

45 24.4a Date(s) of Service - (To Year) N 2 16-17

45 24.4b Place of Service A/N 2 19-20

45 24.4c EMG A 2 22-23

45 24.4d Procedures, Svcs or Supplies

(CPT/HCPCS)

A/N 6 25-30

45 24.4d Procedures, Svcs or Supplies (Modifier

1)

A/N 2 33-34

45 24.4d Procedures, Svcs or Supplies (Modifier

2)

A/N 2 36-37

45 24.4d Procedures, Svcs or Supplies (Modifier

3)

A/N 2 39-40

45 24.4d Procedures, Svcs or Supplies (Modifier

4)

A/N 2 42-43

45 24.4e Diagnosis Pointer N 4 45-48

45 24.4f $ Charges N 8 50-57

45 24.4g Days or Units N 3 59-61

45 24.4h EPSDT Family Plan A 1 63

45 24.4i Legacy Qualifier Rendering Provider

Blank) (Leave

A/N 0

45 24.4j Legacy Provider Number Rendering

Provider

A/N 11 68-78

46 24 Line Detail Narrative A/N 63 01-63

46 24.5i Legacy Qualifier Rendering Provider A/N 2 65-66

46 24.5j Legacy Provider Number Rendering

Provider

A/N 11 68-78

47 24.5a Date(s) of Service - (From Month) N 2 01-02

* M = mark (X), A = alpha, N = numeric

47 24.5a Date(s) of Service - (From Day) N 2 04-05

LINE FIELD LITERAL

FIELD

TYPE* BYTES

COLUMNS

47 24.5a Date(s) of Service - (From Year) N 2 07-08

47 24.5a Date(s) of Service - (To Month) N 2 10-11

47 24.5a Date(s) of Service - (To Day) N 2 13-14

47 24.5a Date(s) of Service - (To Year) N 2 16-17

47 24.5b Place of Service A/N 2 19-20

47 24.5c EMG A 2 22-23

47 24.5d Procedures, Svcs or Supplies

(CPT/HCPCS)

A/N 6 25-30

47 24.5d Procedures, Svcs or Supplies (Modifier

1)

A/N 2 33-34

47 24.5d Procedures, Svcs or Supplies (Modifier

2)

A/N 2 36-37

47 24.5d Procedures, Svcs or Supplies (Modifier

3)

A/N 2 39-40

47 24.5d Procedures, Svcs or Supplies (Modifier

4)

A/N 2 42-43

47 24.5e Diagnosis Pointer N 4 45-48

47 24.5f $ Charges N 8 50-57

47 24.5g Days or Units N 3 59-61

47 24.5h EPSDT Family Plan A 1 63

47 24.5i Legacy Qualifier Rendering Provider

(Leave Blank)

A/N 0

47 24.5j Legacy Provider Number Rendering

Provider

A/N 11 68-78

48 24 Line Detail Narrative A/N 63 01-63

48 24.6i Legacy Qualifier Rendering Provider A/N 2 65-66

48 24.6j Legacy Provider Number Rendering

Provider

A/N 11 68-78

49 24.6a Date(s) of Service - (From Month) N 2 01-02

49 24.6a Date(s) of Service - (From Day) N 2 04-05

49 24.6a Date(s) of Service - (From Year) N 2 07-08

49 24.6a Date(s) of Service - (To Month) N 2 10-11

49 24.6a Date(s) of Service - (To Day) N 2 13-14

* M = mark (X), A = alpha, N = numeric

49 24.6a Date(s) of Service - (To Year) N 2 16-17

LINE FIELD LITERAL

FIELD

TYPE* BYTES

COLUMNS

49 24.6b Place of Service A/N 2 19-20

49 24.6c EMG A 2 22-23

49 24.6d Procedures, Svcs or Supplies

(CPT/HCPCS)

A/N 6 25-30

49 24.6d Procedures, Svcs or Supplies (Modifier

1)

A/N 2 33-34

49 24.6d Procedures, Svcs or Supplies (Modifier

2)

A/N 2 36-37

49 24.6d Procedures, Svcs or Supplies (Modifier

3)

A/N 2 39-40

49 24.6d Procedures, Svcs or Supplies (Modifier

4)

A/N 2 42-43

49 24.6e Diagnosis Pointer N 4 45-48

49 24.6f $ Charges N 8 50-57

49 24.6g Days or Units N 3 59-61

49 24.6h EPSDT Family Plan A 1 63

49 24.6i Legacy Qualifier Rendering Provider

(Leave Blank)

A/N 0

49 24.6j Legacy Provider Number Rendering

Provider

A/N 11 68-78

51 25 Federal Tax ID Number N 15 1-15

51 25 Federal Tax ID Number (SSN) M 1 17

51 25 Federal Tax ID Number (EIN) M 1 19

51 26 Patient's Account Number A/N 14 23-36

51 27 Accept Assignment (Yes) M 1 38

51 27 Accept Assignment (No) M 1 43

51 28 Total Charge N 9 51-59

51 29 Amount Paid N 8 62-69

51 30 Balance Due N 8 71-78

52 33 Billing Provider Phone Number Area

Code

N 3 66-68

52 33 Billing Provider Phone Number N 9 70-78

* M = mark (X), A = alpha, N = numeric

53 32 Name of Facility Where Svcs Rendered A/N 26 23-48

LINE FIELD LITERAL

FIELD

TYPE* BYTES

COLUMNS

53 33 Physician/Supplier Billing Name A/N 29 50-78

54 32 Address of Facility Where Svcs

Rd d

A/N 26 23-48

54 33 Physician/Supplier Address A/N 29 50-78

55 31 Left Blank for Signature

Physician/Supplier

55 32 City, State and ZIP Code of Facility A/N 26 23-48

55 33 City, State and ZIP Code of Billing

P id

A/N 29 50-78

56 32a Facility NPI Number N 10 24-33

56 32b Facility Qualifier and Legacy Number A/N 14 35-48

56 33a Billing Provider NPI Number N 10 51-60

56 33b Billing Provider Qualifier and Legacy

Nb

A/N 17 62-78

* M = mark (X), A = alpha, N = numeric