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Inspect the work · sample claim form

The CMS-1500, filled, boxes numbered.

Every value is fictional and marked so. This is the form a parent's plan actually processes, built from the 9:00 line of the demo day sheet: 90837, F41.1, 55 minutes documented, office. In the product, this renders as a print-ready PDF; this page shows every populated box so a biller can inspect the mapping.

HEALTH INSURANCE CLAIM FORM · CMS-1500 (02-12) · FICTIONAL SAMPLE

Carrier
Payer name and address
EXAMPLE HEALTH PLAN OF CALIFORNIA, PO BOX 100, SACRAMENTO CA 95899
Patient and insured
1. Insurance type
GROUP HEALTH PLAN [X]
1a. Insured's ID number
XZ4400221
2. Patient's name
EXAMPLE, MIRA (fictional)
3. Patient's DOB / sex
03 02 2015 · F
4. Insured's name
EXAMPLE, PARENT (fictional)
5. Patient's address
18 EXAMPLE LANE, SACRAMENTO CA 95899 · (916) 555-0143
6. Relationship to insured
CHILD [X]
7. Insured's address
SAME AS BOX 5
10. Condition related to
EMPLOYMENT [NO] · AUTO ACCIDENT [NO] · OTHER ACCIDENT [NO]
11. Insured's group number
88012
12. Patient's / authorized signature
SIGNATURE ON FILE · DATE 08/27/2026
13. Insured's signature
SIGNATURE ON FILE
Physician or supplier
14. Date of current illness
EMPTY · the day sheet does not contain an onset date, so the engine leaves this box for the clinician; it never fills a gap by guessing
17. Referring provider
NONE
21. Diagnosis (ICD-10)
A: F41.1
24A-J. Service line 1
DOS 08/27/2026 · POS 11 · CPT 90837 · MOD (none) · DX PTR A · CHARGE $250.00 · UNITS 1 · 24J RENDERING NPI 1234567890
25. Federal tax ID
94-0000000 · EIN [X] (not SSN)
26. Patient account no.
MR-0001
27. Accept assignment
NO [X] · out-of-network; patient files for reimbursement
28. Total charge
$250.00
29. Amount paid
$250.00 · paid in full by patient
30. Balance due
$0.00
31. Physician signature
MAYA CHEN MD (fictional) · 08/27/2026
32. Service facility
2140 EXAMPLEWOOD AVE STE 300, SACRAMENTO CA 95899
33. Billing provider / phone
MAYA CHEN MD · 2140 EXAMPLEWOOD AVE STE 300, SACRAMENTO CA 95899 · (916) 555-0142 · 33a BILLING NPI 1234567890 (solo practice: same as rendering) · 33b TAXONOMY 2084P0804X

Boxes not shown (9, 15, 16, 18, 19, 20, 22, 23) are empty on this claim and print empty, as is box 14 above: empty boxes stay empty until the clinician fills them. The NPI is a ten-digit fictional placeholder; the product's format checks pass it and the federal registry is not queried on fictional samples, exactly as stated on the front page.