Block 28 – 32b on CMS 1500 instruction
Billing instruction for Ambulance Billing – Box 28 to32b
| BlockNo. | Block Name | Block Code | Notes |
| 28 | Total Charge | LB | Do not complete this block. |
| 29 | Amount Paid | A | If a patient is to pay a portion of their medical bills as determined by the local County Assistance Office (CAO), enter the amount to be paid by the patient. Patient pay is only applicable if notification is received from the local CAO on a PA 162RM form. Do not enter copay in this block. |
| 30 | Balance Due | LB | Do not complete this block. |
| 31 | Signature of Physician or Supplier Including Degree or Credentials | M/M | This block must contain the signature of the provider rendering the service. A signature stamp is acceptable, except for abortions, if the provider authorizes its use and assumes responsibility for the information on the claim. If submitting by computer-generated claims, this block can be left blank; however, a Signature Transmittal Form (MA 307) must be sent with the claim(s). Enter the date the claim was submitted in this block in an 8-digit (MMDDCCYY) format (e.g. 03012004). |
| 32 | Service Facility Location Information | LB | Do not complete this block. |
| 32a | LB | Do not complete this block. | |
| 32b | LB | Do not complete this block. |
Billing instruction for Ambulance Billing – Box 28 to32b
| BlockNo. | Block Name | Block Code | Notes |
| 28 | Total Charge | LB | Do not complete this block. |
| 29 | Amount Paid | A | If a patient is to pay a portion of their medical bills as determined by the local County Assistance Office (CAO), enter the amount to be paid by the patient. Patient pay is only applicable if notification is received from the local CAO on a PA 162RM form. Do not enter copay in this block. |
| 30 | Balance Due | LB | Do not complete this block. |
| 31 | Signature of Physician or Supplier Including Degree or Credentials | M/M | This block must contain the signature of the provider rendering the service. A signature stamp is acceptable, except for abortions, if the provider authorizes its use and assumes responsibility for the information on the claim. If submitting by computer-generated claims, this block can be left blank; however, a Signature Transmittal Form (MA 307) must be sent with the claim(s). Enter the date the claim was submitted in this block in an 8-digit (MMDDCCYY) format (e.g. 03012004). |
| 32 | Service Facility Location Information | LB | Do not complete this block. |
| 32a | LB | Do not complete this block. | |
| 32b | LB | Do not complete this block. |