How to fill form A for insurance claim?


Editorial team Published on

To fill out an insurance claim form (such as a health or medical claim form like Part A or a CMS-1500 style document), follow these steps:

1. Gather Required Documents

  • Your Insurance Card: To pull the policy number, group number, and member ID.
  • Itemized Bills and Receipts: Provided by your doctor or hospital, showing the exact date of service, description, and cost.
  • Diagnosis and Procedure Codes: ICD-10 diagnosis codes and CPT/HCPCS procedure codes from your provider.
  • Explanation of Benefits (EOB): If you have primary or secondary insurance coverage.

2. Complete Section A: Insured & Patient Details

  • Policy / Certificate Number: Enter your assigned insurance policy number or social health insurance number.
  • Primary Insured Information: Write the full name, date of birth, address, and contact details of the person who holds the policy.
  • Patient Information: Fill in the patient's full name, sex, date of birth, and relationship to the primary insured (e.g., self, spouse, child).
  • Other Insurance: Indicate whether there is another health benefit plan and provide those policy details if applicable.

3. Complete Section B: Claim & Medical Details

  • Date of Service: Enter the exact date(s) the medical treatment or service occurred.
  • Place of Service Code: Enter the appropriate code (e.g., code 11 for a standard doctor's office visit).
  • Diagnosis & Procedure Codes: List the diagnosis codes (such as DSM-5 or ICD-10) and CPT codes for the specific services performed.
  • Charges: Write down the billed amount for each individual service line.

4. Review and Sign

  • Authorization to Release Information: Sign to allow the insurance company to contact your medical provider for records.
  • Payment Assignment: Decide whether you want reimbursement sent directly to you or paid straight to the doctor/supplier, and sign the appropriate box.
  • Sign and Date: Ensure the policyholder or patient signature and current date are included at the bottom. Do not leave required sections blank, as incomplete forms will be returned.

5. Attach & Submit

  • Attach all itemized bills, proof of payment, and supporting medical notes or EOBs.
  • Make a copy of the completed form and all attachments for your own records.
  • Mail, fax, or submit the digital form through your insurer's official portal (such as via your provider's instructions or a dedicated address like Medica Claim Forms).