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Sample Request Form

Sample Request

Thank you for your interest in our products. We provide free samples on a limited basis to continental US based addresses only - reviewing each request individually. We do sell as few as 10 CMS 1500 forms economically ($2.50) to help those of you not sure this form will work for you, or if you're a very small practice that doesn't submit many claim forms. So please thoughtfully submit requests for our samples if you believe you have a valid reason to receive one for free. 

If you're unsure about the difference between products, a brief description of each of our most popular products is listed below. Please contact us if you need further clarification:

CMS 1500 forms, general info: formerly known as HCFA 1500 forms, the new CMS 1500 forms include a space for the NPI number. Used to file medical claims to insurance carriers including Medicare, Medicaid, BCBS, etc. for standard medical procedures.

CMS 1500 form - 1 part laser
A single sheet of paper, used with laser or inkjet printers, but can also be hand-written
CMS 1500 form - 2 part handwritten
A 2-part form, white and yellow paper, makes a carbon copy, can be typed or hand-written
CMS 1500 form - 1 part pinfeed
A 1-part form, with pinfeed on both sides. Otherwise known as continuous or tractor feed
CMS 1500 form - 2 part pinfeed
A 2-part form, with pinfeed on both sides. Otherwise known as continuous or tractor feed. Choose from white/white or white/yellow paper sequence
CMS 1500 No. 10 envelope
The #10 window envelope developed to work with the new CMS 1500 forms
CMS 1500 Catalog-Large envelope
The large 9x12 first class window envelope with "do not bend, important documents enclosed"

UB04 forms general info: formerly known as UB92s, the new UB04s include a space for the NPI number. Used to file medical claims to insurance carriers for Medicare Part A claims, mostly used by Hospitals
UB04 - 1 part laser
A single sheet of paper, otherwise known as the CMS-1450, used to file hospital claims

ADA Forms general info: used in dental offices. ADA stands for American Dental Association.
2006 ADA Claim Form - 1 part laser
A single sheet of paper, used to file dental medical claims,

1.*First Name


2.*Last Name


3.Company Name


4.*Street Address - line 1


5.Street Address - line 2


6.*City


7.*State (abbreviation)


8.*Zip Code


9.Phone Number


10.*Email Address


11.Reason for request - please briefly describe the purpose for your free sample request. Supplies are limited.


12.*Please check the box(es) of the medical insurance claim forms or insurance envelope samples you would like to receive. If your request is accepted, you will receive two of each form you request. Thank you.
CMS 1500 form - 1 part laser
CMS 1500 form - 2 part handwritten
CMS 1500 form - 1 part pinfeed
CMS 1500 form - 2 part pinfeed
CMS 1500 No. 10 envelope
CMS 1500 Catalog-Large envelope
UB04 - 1 part laser
2006 ADA Claim Form - 1 part laser



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