Why ICD-10 not ICD-9?

US healthcare moved to ICD-10 in 2015. ICD-9 is legacy.

What goes in "Dx pointer"?

A reference to which diagnosis code applies to that service line — e.g. "A" pointing back to the first ICD-10 code in section 3. Standard CMS-1500 convention.

Insurance Claim Form

Generate a printable health-insurance claim form PDF — patient + provider + service + diagnosis + charge sections, in CMS-1500-style layout.

Your files never leave your browser. All processing happens on your device — nothing is uploaded.

1. Upload your file

Drop a PDF file here

or click to browse

2. Options

Practice / billing entity

How does the Insurance Claim Form work?

Generate a printable health-insurance claim form PDF in CMS-1500-style layout — patient information, insured/subscriber, diagnosis codes (ICD-10), services table (date of service / place of service / CPT / modifier / dx pointer / charge / units / NPI), totals, and provider signature. Caveat: this is a STYLED-AFTER form, not the actual CMS-1500 (which has copyrighted red drop-out ink and is filed via clearinghouses). Use the actual CMS-1500 form for actual claim submission; this template is for tracking, internal records, or patient hand-off ("here's what we're billing").

🔒 Security & Privacy

All processing happens on your device. Your files never leave your browser, never touch our servers, and are not stored anywhere. Close the tab and the file is gone.

📱 Use it on any device

Works in any modern browser — Mac, Windows, Linux, iPhone, Android, and tablets. No installation, no app to download. Just open the page and start.

⚡ Quick & easy

Drag, drop, click. Most files process in seconds, not minutes. No watermarks added to your output, no per-day limits, and the tool always shows the result before asking you to download.

🎁 Always free, no signup

Free to use, every time. No account creation, no email required, no “trial” that converts to a paid plan. We make money from ads so you don’t have to pay.

Frequently asked

No — actual claim submission requires the official red-drop-out CMS-1500 form (paper) or the 837P EDI standard (electronic via clearinghouse). This is a styled-after copy for record-keeping.