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CHMO
Medicare
Medicaid
Lovelace Member ID (Required)
Patient Account Number (Box 26 CMS 1500 Form)
Member SSN (no hyphens)
Member Last Name (Required)
Member First Name (Required)
Member DOB
Month
Month January
February
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April
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Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Year Year 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910
Provider TIN (Box 26 CMS 1500 Form) (Required)
Provider Servicing Name (Box 31 CMS 1500 Form) (Required)
Provider Billing Name (Box 33 CMS 1500 Form)
From DOS (Required)
Month
Month January
February
March
April
May
June
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August
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October
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December
Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Year Year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998
To DOS
Month
Month January
February
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April
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June
July
August
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October
November
December
Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Year Year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998
Procedure Code
Modifier
Units Billed
Billed Amount (Required)
Date Submitted to Lovelace
Month
Month January
February
March
April
May
June
July
August
September
October
November
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Year Year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910
Paper or EDI Submittal?
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Paper
EDI
Provider Comments
Detailed Instructions
