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
27% off
$19.59
25+ pad
$0.20/EACH
Order in multiples of 5
100 EACH = 1 PAD
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$26.99
5 pad
8%
$24.79
10 pad
14%
$23.29
15 pad
20%
$21.49
20 pad
27%
$19.59
25 + pad
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Custom Carbonless CMS Forms, 8-1/2" x 11", 100 Sheets per Pad
Frequently bought together
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Sale
Item #: 901-QCBC00126
20% off
$56.79
1 pack
($0.23/EACH)
82% off
$12.63
20+ pack
($0.05/EACH)
$56.79
+
Sale
Total
$210.63
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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"
