I hope you realize that the upper screenshot represents the pdf output to fill in a blank CMS1500 form. You would then select to print to your printer which has the paper being those blank forms, which are printed in red ink. Payer and clearinghouse portals scan them with a red filter, and use OCR technology to look at the coordinate locations for text. The “x” marks are checks in boxes you will find on the forms.
The lower image is the statement output which is easily modified to whatever you want in text. For example, the distribution includes info on paying with credit card which you have obviously changed as my clients have who do not accept credit cards. I urge you to verify the page break as not all systems and printers work with the file as distributed.