HOME Just CMS 1500 Forms
> New CMS 1500 Claim Form Version 02/12> Imprinted CMS 1500 Forms

New Imprinted CMS-1500 (HCFA) Form Version 02/12, 2-Part, for Handwritten Claims - 250 Pack

New Imprinted CMS-1500 (HCFA) Form Version 02/12, 2-Part, for Handwritten Claims - 250 Pack
click to see larger image
Name: New Imprinted CMS-1500 (HCFA) Form Version 02/12, 2-Part, for Handwritten Claims - 250 Pack
Your Price:
As low as $54.00
Serial Number: L0294I



The Centers for Medicare & Medicaid Services (CMS) approved a new CMS-1500 form (02/12) to replace the previous form (08/05). Fully updated with the latest revisions, the new CMS-1500 form is 100% compliant and printed to exact specifications for layout, paper and ink.

 

·         2-part carbonless -- Top sheet color is white, second sheet color is yellow

·         50 sheets per pad, 5 pads per set (1 set = 250 CMS-1500 forms)

·         Preprinted with certain information, such as physician’s name and address, for added convenience

·         Uses soy-based black and OCR "dropout” red ink for greater scanning accuracy

·         Printed on SFI (Sustainable Forestry Initiative) paper

·         Features Anti-Rejection Projection™* -- guaranteed acceptance by insurance carriers for rejection-proof claim filing and quicker payment

250 forms per set, 1 set minimum.

Ships in 7-10 business days.

Imprinting in10-pt. Helvetica font.

 

Interested in a free sample? Click here.

 

We offer the fill-in blanks below as a courtesy, based on customer requests for preprinted fields. It is your responsibility to enter the correct information. We recommend that you’ve already submitted a claim and had it processed and approved before submitting an imprint order.
 
Forms will start shipping 8/1/2013.
 
 

12. Patient's or Authorized Person's Signature


13. Insured's or Authorized Person's Signature


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 (i.e. 1234567890). Report the Identification Number in items 24I and 24J only when different from data recorded in items 33a and 33b.

24J - Lines 1-6

Enter "Yes" to add Other ID# and Rendering Provider ID to lines 1-6 in 24J.

25. Federal Tax Identification Number

Federal Tax ID Number. Do not enter hyphens with numbers.

25. Checkbox SSN or EIN for Federal Txa 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 will not be printed.

32a. NPI #

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 #


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

Special instructions or additional fields not mentioned above

Bulk Pricing:
Min Qty Price Per Unit
1 $58.00
2 $56.00
5 $54.00
Quantity To Order:
 

Product Reviews

Write an online review and share your thoughts.
 

Customers who bought this item also bought

New Imprinted CMS-1500 (HCFA) Form Version 02/12 for Laser Printers - Carton of 2500
New Imprinted CMS-1500 (HCFA) Form Version 02/12 for Laser Printers - Carton of 2500
$149.65 per carton
Click here for more details
New Blank CMS-1500 (HCFA) Form Version 02/12 and Envelope Sets
New Blank CMS-1500 (HCFA) Form Version 02/12 and Envelope Sets
As low as $47.63
Click here for more details
New CMS-1500 (HCFA) Form 02/12, 1-Part, for Pinfeed Printers
New CMS-1500 (HCFA) Form 02/12, 1-Part, for Pinfeed Printers
as low as $36.25
Click here for more details


*If a CMS-1500 form is rejected by an insurance carrier due to improper formatting or print quality, we will provide a full replacement order of the purchaser’s forms. To qualify, you must notify us no later than 20 days after the rejection letter is issued. Upon review of the rejection letter and confirmation that the rejected forms were manufactured by us, we will send a full replacement order of the affected items. This Anti-Rejection Protection™ limited warranty applies to rejections based on the form itself being invalid due to ink quality or formatting, such as data elements being improperly positioned or misaligned. This protection does not apply to missing or incorrect entries provided by the user.


100% Safe shopping

Frequently Asked Questions
Privacy Policy
Testimonials
CMS 1500 Forms Information
Return Policy
Instruction Manual
HCFA CMS-1500 Form
Sample Requests
Helpful Information
Shipping Policy
Hawaii and Alaska Customers
Sitemap
CMS 1500 Notices
About Us
Payment Options
Order Tracking