IMPRINTED-New CMS 1500 (08/05) 2-Part Forms For Hand Written Claims - Cartons of 500
Your Price:
From $46.50 to $125.00 per carton
Serial Number:
WCMS-1500-U2imp
2 Part Hand Written CMS 1500 Forms, imprinted. 500 per carton. 1 carton 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 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. A mock-up of your cms 1500 form will be emailed to you within 48 hours. After the mock-up is approved, we will then send a formal Proof to you for approval. This may take a week. 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.
500 per carton. 1 carton minimum order.
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.
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.
Other printing instructions, ie. checkmark line 1-Medicare
Type in printing instructions, ie. checkmark line 1 "Medicare".
