Custom Carbonless CMS Forms, 8-1/2" x 11", 100 Sheets per Pad
$26.99
5 pad
($0.27/EACH)
Save 27%
$19.59
25 pad
($0.20/EACH)
Custom Carbonless CMS Forms, 8-1/2" x 11", 100 Sheets per Pad
Item #:
901-QFW1471901
Model #:
7QGFM1471901
Brand:
Quill Custom Print
(1 reviews)
Item #:
901-QFW1471901
$26.99
5 pad
$0.27/EACH
Save 27%
$19.59
25 pad
$0.20/EACH
Order in multiples of 5
100 EACH = 1 PAD
Buy more & save!
Qty. savings
$26.99
5 pad
8%
$24.79
10 pad
14%
$23.29
15 pad
20%
$21.49
20 pad
27%
$19.59
25 pad
Want an extra discount today, and every day? Start your free trial.
Custom Carbonless CMS Forms, 8-1/2" x 11", 100 Sheets per Pad
Frequently bought together
+
Item #: 901-QCBC00126
$70.99
1 pack
($0.28/EACH)
Save 78%
$15.79
20 pack
($0.06/EACH)
$70.99
Total
$205.94
Customers also viewed
Custom 2-Part Numbered Charge Slip Forms, 8-1/2" x 11", 1000 Sets per Pack
Item #: 901-QFW1053801
Custom Carbonless 2-Part Equine Superbills, 8-1/2" x 11", 250 Sets per Pack
Item #: 901-QFN103481R
Custom Registration Forms, 8-1/2" x 11", 250 Sheets per Pack
Item #: 901-QFN105XX1R
Custom Welcome Registration and History Forms, 8-1/2" x 11", 250 Sheets per Pack
Item #: 901-QFN117541R
Custom Carbonless 2-Part Examination Report Forms, 4" x 5-1/2", 50 Sets per Pad
Item #: 901-QFN131141R
Custom HIPAA Privacy Practice Acknowledgment Forms, 8-1/2" x 11", 200 Sheets per Pack
Item #: 901-QFN155811R
Custom Treatment Notes, 8-1/2" x 11", 250 Sheets per Pack
Item #: 901-QFN105601R
Custom Feline Pet Treatment Records, 8-1/2" x 11", 250 Sheets per Pack
Item #: 901-QFW2056301
Custom Dental Charge Slips, 4" x 5-1/2", 100 Sheets per Pad
Item #: 901-QFN131151R
Custom X-Ray I.D. Cards, 5" x 3", 250 Cards per Pack
Item #: 901-QFN101XID1R
Custom Privacy Notices Fax Cover Slips, 8-1/2" x 11", 100 Sheets per Pad
Item #: 901-QFN10XXX1R
Custom 2-Sided Pegboard Account Cards, 5-1/2" x 8-1/2", 500 Cards per Pack
Item #: 901-QFN101291R
Custom 1-Sided Pegboard Account Cards, 5-1/2" x 8-1/2", 110# Index Stock, 500 Cards per Pack
Item #: 901-QFN101351R
Description
Accommodates reporting of the NPI number and is approved by the AMA's Council on Medical Services and CMS.
- For use by all medical facilities for billing insurance companies, Medicaid and Medicare; aligned with the electronic HIPAA ASC X12N 837 Non-institutional Transaction Standard
- 8-1/2" W x 11" L
- 1-part, white, carbonless; carbon paper is required for duplicates
- 100 sheets per pad, order in quantities of 5 pads
- Printed on recycled paper
- Option to personalize tax ID#, service facility location and provider information
Specifications
# Up Per Sheet/Page
1
Binding Type
Padded
Brand
Quill Custom Print
Carbonless
Yes
Color
White
Customizable
Yes
Form Size
8 1/2" x 11"
Form Type
Medicare
Format
Medical Complaint Form
Holes Punched
No
Lines
Varies
Media Quantity
100
NCR Paper
Yes
Number of Parts
1
Numbered
Yes
Package Quantity
100 per Pad
Personalization
Yes
Security Features
No
Sheet Size
8 1/2" x 11"
