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

_ Instructions for Completing the OMS-1500 (02/12) Claim Form (continued) Item Number, Name, and Use (R = required: C = conditional, depending on claim) Source Document Item 15: Other Dale (G) Encounter form Item 15 reports other dates related to the patient’s condition or treatment. Use the 6-digit Medical record (MMDDYY) or 8-digit (MMDDCCYY) format. Enter the applicable qualifier between the vertical, dotted lines after the word “Qualifier" to identify which date is being reported. 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-ray 471 Prescription 444 First Visit or Consultation Previous pregnancies are not a similar illness. Leave this field blank if unknown.