CMS-1500 Rev. (02/12); 2-Part Pin-feed, White/White, 1,000/Box

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Item # 901-CMS12W2
  Model # CMS12W2
• Form Type: Billing • Format: Health Insurance Claim Form • Sheet Size: 9-1/2" x 11"
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  • Approved by the National Uniform Claim Committee (NUCC); HIPAA compliant
  • This form was revised to align the paper form with some of the changes in the electronic health care claims: Professional (837), 005010X222 Technical Report Type 3 (5010) and 005010X222A1 Technical Report Type 3 (5010A1)
  • The most significant change was the addition of 8 diagnosis codes in field 21
  • Includes new QR code identifier at the top of the form that supports and aligns with Industry scanning systems
  • Printed with OCR "dropout" red ink on 20lb. paper (per government regulations)
  • Form not available personalized
  • Certified Chain of Custody; promotes sustainable forest management
  • Size: 8-1/2x11"
  • 1,000 per box
  • To view the 02/2012 proposed changes for this product Click Here

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CMS-1500 Rev. (02/12); 2-Part Pin-feed, White/White, 1,000/Box
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