HCFA-1500 Box 5 - Patient's Address

On the HCFA-1500 form, box 5 is designated for the patient's street address, city, state, zip code and telephone number. This is the patient who the services were rendered to on the claim.

In our example below, we populated box 5 with the street address'123 Main Street', city 'Anytown', state 'NE', zip code '12345' and the telephone number '415-555-0132'.

Note: The full 9-digit zip code is optional and only the 5-digit zip code is required. If the last 4-digits of the full 9-digit zip code are unknown, it's often acceptable to use 0000 or 9999. Example: 12345-0000

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

In the X12 837 format, the patient's address box information goes in the 2010CA Patient Name Loop - N3/N4 segments. More specifically, the HCFA box 5 patient's address data goes in the N301, N401, N402 and N403 segment/data elements.

The 2010CA Patient Name Loop is only sent when the patient and subscriber are NOT the same. If they are the same, then you would populate the 2010BA Subscriber Name Loop - N3/N4 segments. You can pull the data from patient box as it's common for the subscriber info to be blank when the patient is the subscriber.

The example below shows the 2010CA Patient Name Loop for both the 5010/4010 format - N3/N4 segments. Remember that you only send the 2010CA Patient Name 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.

Note: There is no 837 location for the patient telephone number.

Sample 837P (5010) - 2010CA - Patient Name

Sample 837P (4010) - 2010CA - Patient Name

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
• HCFA-1500 Box 4 - Insured's Name
• HCFA-1500 Box 5 - Patient's Address [You are Here]
• 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