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

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Item # 901-CMS122
  Model # CMS122
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CMS-1500 Rev. (02/12); 2-Part Pin-feed, White/Yellow, 1,000/Box
$69.99 Box
$62.99 /Box
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  • Form Type: Billing
  • Format: Health Insurance Claim Form
  • Sheet Size: 9-1/2" x 11"
  • 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
Product Information Form Type : Billing Format : Health Insurance Claim Form
Sheet Size : 9-1/2" x 11" Lines : No Lines
Form Size : 8-1/2" x 11" Media Quantity : 1000
Binding Type : Continuous Paper Color : White
Number of Parts : 2 Carbonless : Yes
# Up Per Sheet/Page : 1 NCR Paper : Yes
Numbered : No Holes Punched : None
Personalization : No Security Features : No
Environmental Information Certifications & Standards : SFI Sustainable Forestry Iniative Post-Consumer Waste% : 0
Miscellaneous Country of Origin : USA Brand : N/A
Weight Weight : 1.00 lbs. per Box

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