HCFA-1500 Box 3 - Patient's Birth Date and Sex

On the HCFA-1500 form, box 3 is designated for the patient's birth date and sex. This is the patient who the services were rendered to for the claim. Check the box for the patient's sex and enter the patient's birth date using the complete 4-digit year.

In our example below, we populated box 3 with the date of birth '01 01 1980' and the gender as 'M'. Notice the date is shown without hyphens/slashes as the form already has visual separators for the date.

So far, we talked about what the patient's birth date and sex on the HCFA form are and the information used to populate this location. In the next section, we'll briefly discuss the patient's birth date and sex in relation to the X12 837 format.

In the X12 837 format, the patient's birth date and sex information will go in the 2010CA Patient Demographic Information Loop - DMG segment. More specifically, the HCFA Box 3 patient's birth date data goes in the DMG02 segment/data element and the HCFA box 3 sex data will go in the DMG03 segment/data element. If the patient is the same person as the subscriber, then you would only send that information in the 2010BA Subscriber loop and not in the 2010CA Patient Loop.

The example below shows the 2010CA Patient Demographic Information Loop and the 2010BA Subscriber Demographic Information Loop - DMG segment. Remember that you only send the 2010CA Patient Loop if the patient is not the same person as the subscriber. For additional information on the X12 837 format, we strongly recommend consulting the official X12 materials. Please refer to the HCFA box 4 Insured's Name document for more details and an example of the 2010BA Loop.

Sample 837P (5010) - 2010CA - Patient Demographic Information

Sample 837P (5010) - 2010BA - Subscriber Demographic Information

HCFA-1500 Form Box Locations

• HCFA-1500 Box 0 - Carrier Block
• HCFA-1500 Box 1 - Insurance Type
• HCFA-1500 Box 1a - Insured's ID Number
• HCFA-1500 Box 2 - Patient's Name
• HCFA-1500 Box 3 - Patient's Birth Date and Sex [You are Here]
• HCFA-1500 Box 4 - Insured's Name
• HCFA-1500 Box 5 - Patient's Address
• HCFA-1500 Box 6 - Patient Relationship to Insured
• HCFA-1500 Box 7 - Insured's Address
• HCFA-1500 Box 8 - Reserved For NUCC Use

Grab a sample of the HCFA-1500 claim form here - HCFA 02/12 Claim Form