Thursday, June 24, 2010

CMS 1500 box 10 A - C

Field Name -

Is the patient’s
condition related to:
•Auto accident?
• Other accident?


Place an "X" in the box indicating whether or not
the condition for which the patient is being
treated is related to current or previous
employment, an automobile accident or any other
accident. Enter an "X" in either the YES or NO
box for each question

NOTE: The state postal code must be shown if
“yes” is marked in 10b for “auto accident”. Any
item marked yes indicates there may be other
applicable insurance coverage that would be
primary such as automobile liability insurance.
Primary insurance information must then be
shown in item 11.

10d Reserved for local use Not required Please leave blank.

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