Block 28 - 32b on CMS 1500 instruction


Billing instruction for Ambulance Billing - Box 28 to32b

BlockNo.Block NameBlock CodeNotes
28Total ChargeLBDo not complete this block.
29Amount PaidAIf a patient is to pay a portion of their medical bills as determined by the local County Assistance Office (CAO), enter the amount to be paid by the patient. Patient pay is only applicable if
notification is received from the local CAO on a PA 162RM form. Do not enter copay in this block.
30Balance DueLBDo not complete this block.
31Signature of Physician or Supplier Including Degree or CredentialsM/MThis block must contain the signature of the provider rendering the service. A signature stamp is acceptable, except for abortions, if the provider authorizes its use and assumes responsibility for the information on the claim. If submitting by computer-generated claims, this block can be left blank; however, a Signature Transmittal Form (MA 307) must be sent with the claim(s).
Enter the date the claim was submitted in this block in an 8-digit (MMDDCCYY) format (e.g.
32Service Facility Location InformationLBDo not complete this block.
32aLBDo not complete this block.
32bLBDo not complete this block.