IMPRINTED-NEW CMS 1500 Forms (08/05) for laser printers - 2500 per carton. Pre-imprint your laser cms 1500 forms with repetitive information such as physician's name and address, NPI number...
These cms 1500 forms also work in inkjet printers or can be handwritten.
Want samples mailed to you? Click here to request your CMS 1500 forms sample. 1 part OCR scanable paper. Black and red ink. 100% compatible with UCCI requirements. These are the NEW CMS 1500 forms mandated by the U.S. Centers for Medicare and Medicaid Services (CMS) to be in use by July 1, 2007, adding the split provider identifier fields for NPI numbers.
Minimum order is 2500 laser compatiible 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 10 work days to ship.
*We offer the fill-in blanks below as a courtesy. They are fields others have requested to be pre-printed. 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.
Shipping charge is $8.00/ctn to the continental US.
2500 cms 1500 forms per carton. Minimum order is 2500 CMS 1500 forms.
12. Patient’s or Authorized Person’s Signature
Type "none" in this box if you do not want "signature on file" in this box.
13. Insured’s or Authorized Person’s Signature
Type "none" in this box if you do not want "signature on file" in this box.
17a. The Other ID number of the referring, ordering, or supervising provider
Should look something like "1C 123456789"
17b. NPI#
NPI#
24i. ID Qualifier
Should look something like "1C"
24j-top line. Other ID# of the rendering provider
Should look something like "123456789" (after the "1C"). Report the Identification Number in Items 24I and 24J only when different from data recorded in items 33a and 33b.
24j-bottom line. Rendering Provider ID #
NPI number (ie. 1234567890). Report the Identification Number in Items 24I and 24J only when different from data recorded in items 33a and 33b.
25. Federal Tax ID Number
Federal Tax ID Number
Do not enter hyphens with numbers.
25. Checkbox SSN or EIN for Federal Tax ID Number
SSN or EIN?
32. Service Facility Location Information
1st Line – Name
2nd Line – Address
3rd Line – City, State and Zip Code
Do not use commas, periods, or other punctuation in the address. When entering a 9 digit zip code, include the hyphen. To separate lines, please type a hyphen, which won't be printed.
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
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. To separate lines, please type a hyphen, which won't be printed.
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.
Other printing instructions, ie. checkmark line 1-Medicare
Type in printing instructions, ie. checkmark line 1 "Medicare".
