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New Imprinted CMS-1500 (HCFA) Form Version 02/12 and Envelope Sets

New Imprinted CMS-1500 (HCFA) Form Version 02/12 and Envelope Sets
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Name: New Imprinted CMS-1500 (HCFA) Form Version 02/12 and Envelope Sets
Your Price:
As low as $101
Serial Number: L0287I
Manufacturer Name: Select your imprinted set size from the drop down menu below.



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. Purchase the forms and corresponding envelopes together … and save 25%!

 

Forms:

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

·         Printed on SFI (Sustainable Forestry Initiative) paper

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

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

Envelopes:

·         Standard 4 ½” x 9 ½”, self-seal envelope

·         Right window format

·         Accommodates up to 12 folded CMS-1500 forms

·         Up to 4 lines of imprinting available in Goudy font; first line is 14-pt. size, other lines are 12-pt. size.

 

Bundled in sets of 1,000 or 2,500 (includes 1,000 or 2,500 CMS-1500 forms, PLUS 2 or 5 boxes of 500 CMS-1500 envelopes).

 

Interested in a free sample? Click here.

 

Save 25% When You Bundle!

 

Item

Retail Price

Bundled Price

Your Savings

2500 CMS-1500 Forms

$146.65

$109.99

$36.66

2500 CMS-1500 Envelopes

$187.50

$140.63

$46.87

TOTAL

$334.15

$250.62

$83.53


 

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.

 

 

Imprinted Form and Envelope Sets:
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Envelope Imprinting


Field 12 Patient or Authorized Person Signature

e.g., SIGNATURE ON FILE

Field 13 Insured or Authorized Person Signature

e.g., SIGNATURE ON FILE

Field 17a The Other ID number of the referring, ordering, or supervising provider

Should look something like "1C 123456789"

Field 17b NPI#


Field 24i ID Qualifier

Should look something like "1C"

Field 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.

Field 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.

24J - Lines 1-6

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

Field 25 Federal Tax ID Number

Federal Tax ID Number Do not enter hyphens with numbers.

Field 25 Checkbox SSN or EIN for Federal Tax ID Number


Field 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.

Field 32a NPI number

Enter the NPI number of the service facility location in 32.

Field 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.

Field 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.

Field 33a NPI#

Enter the NPI number of the billing provider in 33.

Filed 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


Bulk Pricing:
Min Qty Price Per Unit
1000 $101.00
2500 $250.62
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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