IMPRINTED-New CMS 1500 (08/05) 2-Part Forms For Hand Written Claims - Packs of 250
Your Price:
From $26.15 to $45.00 per set
Serial Number:
70163-1
2 Part Hand Written CMS 1500 Forms, imprinted. 250 per set. 1 set of 250 minimum. Ships in 24 hours.
IMPRINTED-New CMS 1500 forms for hand written claims. Want samples mailed to you? Click Here. 2 part carbonless (NCR) paper. Top sheet color: white Bottom sheet color: yellow
Padded in sets of 50, 5 pads per set of 250. 1 set = 250 2-part CMS 1500 forms OCR scanable paper. Black and red ink. 100% compatible with UCCI requirements. This is the NEW CMS 1500 (08/05) form mandated by the U.S. Centers for Medicare and Medicaid Services (CMS) to be in use by April 2, 2007, extended tentatively to July 1, adding the split provider identifier fields for NPI numbers. Minimum order is 500 imprinted CMS 1500 forms.
To download the most current CMS 1500 forms' manual, please click here. *This product requires a proof. After Proof Approval, the order will take 5-10 work days to ship.
*This product only offers these fields to be pre-imprinted:
box 17b: NPI # box 25 federal tax is number 1 line max, x in either ssn or ein box box 32: 3 lines max box 32a: NPI# box 32b: group # box 33: 3 lines max+ 1 phone line box 33a: NP# box 33b: group #
*It is your responsibility to make sure you print the correct information. A recommendation is that you've already submitted a claim with the information and had it processed and approved before submitting an imprint order.
1 pack = 250 forms
2 packs = 500 forms
3 packs = 750 forms
4 packs = 1000 forms
250 per set. 1 set minimum order.
17b. NPI#
NPI#
25. Federal Tax ID Number
Federal Tax ID Number Do not enter hyphens with numbers.
32. Service Facility Location Information
1st Line – Name 2nd Line – Address 3rd Line – City, State and Zip Code. To separate lines, please type a hyphen, which won't be printed. Instructions: Do not use commas, periods, or other punctuation in the address. When entering a 9 digit zip code, include the hyphen.
32a. NPI number.
Enter the NPI number of the service facility location in 32.
32b. Other ID#
Enter the two digit qualifier identifying the non-NPI number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number.
33. Billing Provider Info & Ph #.
Enter the provider’s or supplier’s billing name, address, zip code, and phone number. Enter the name and address information in the following format: 1st Line – Name 2nd Line – Address 3rd Line – City, State and Zip Code. To separate lines, please type a hyphen, which won't be printed. Instructions: Do not use commas, periods, or other punctuation in the address. Enter a space between town name and state code; do not include a comma. When entering a 9 digit zip code, include the hyphen. Do not use a hyphen or space as a separator within the telephone number.
33a. NPI#
Enter the NPI number of the billing provider in 33.
33b. Other ID#
Enter the two digit qualifier identifying the non-NPI number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number.
