Paper Claim Forms
CMS-1500
For non-facility-based professional services
For more information about the CMS-1500 form, visit the National Uniform Claim Committee’s website. Contact your claim forms vendor or one of the following sources to obtain full-color versions of the CMS-1500.
American Medical Association
P.O. Box 10946
Chicago, IL 60610
Attn: Order Department
1-800-621-8335
U.S. Government Printing Office
Superintendent of Documents
Washington, DC 20402
(202) 512-1800
UB-04 (formerly UB-92)
For facility-based professional services
For more information about the UB-04 form, visit the National Uniform Billing Committee’s website. Contact your claim forms vendor to obtain full-color versions of the UB-04.
Magellan’s EASI Form
For EAP reimbursement
To receive payment for Employee Assistance Program (EAP) services rendered, you must complete and submit the Employee Assistance Service Information (EASI) Form.