Instructions for Completing the CMS-1500 (02/12) Claim Form Continued

- Instructions for Completing the CMS-1500 (02/12) Claim Form (continued) Item Number, Name, and Use (R = required; ' ' nal, depending on claim) Source Document Item 241: Rendering Provider (R) Encounter form The provider rendering the service is reported in Item 24J. Enterthe NPI number in the unshaded Medical record area of the field. If the insurance plan also requires use of a plan»specific provider ID number for the provider who delivered the service, or the provider does not have an NPI, enter Qualifier in 24! and the other ID number in the shaded portion of 24J. Otherwise, leave the shaded portion blank. Item 25: Federal Tax I.D. Number (R) Encounter form In Item 25, enter the provider’s federal tax ID number or the employer identification number (EIN) Office records of the billing entity. This number should be consistent with the billing provider listed in Item 33. Do not enter hyphens with numbers. The appropriate box (SSN or EIN) should be marked with an X.