How to Complete Claim Form 1450

1). Gather the information you need to complete Claim Form 1450. You need to have your contact information on hand, your federal tax number, the patient's information (including contact information, birth date, gender, dates admitted, priority of condition and date discharged) and the billing information.
2). Print out a copy of Form 1450's instructions. Copies may or may not be included with the form itself; for convenience, check the Resource section below for Form 1450 Instructions.
3). Place Claim Form 1450 in front of you. Clear space to place the information you gathered in Step 1. Next to Claim Form 1450, place the Form Instructions printed out in Step 2.
4). Start with Line 1 and work you way through the form. Note that some fields are optional (such as lines 3a and 3b and line 43), some are conditional based on the patient and type of case (such as lines 16 and lines 18-28) and some are not required at all (such as line 30). Refer to the instructions for which lines you must fill in. Use the information from step 1 to fill in the form.
5). Sign and date the form. Send the form to your State's Medicaid Agency.