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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
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Name: New Imprinted CMS-1500 (HCFA) Form Version 02/12 for Laser Printers - Carton of 2500
Your Price:
As low as $110.50
Serial Number: L0293I



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.

 

·         Designed for laser printers or inkjet printers, can also be handwritten

·         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

 

2,500 forms per carton, 1 carton minimum.

Ships in 7-10 business days.

Imprinting in Arial 10-pt. 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.

 

 

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 number (i.e. 1234567890).

24I. ID Qualifier

Should look something like "1C"

24J-top line. Other ID# of the rendering provider

Should look something like "123456789" (after the ID Qualifier). 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 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 comma, 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 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 #


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

Type in printing instructions (e.g., "Checkmark line 1 "Medicare"")

Bulk Pricing:
Min Qty Price Per Unit
1 $146.65
2 $123.70
3 $116.50
10 $110.50
Quantity To Order:
 

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*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.

 

 


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