Dot-Matrix Health Insurance Forms
(6 Products)
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ComplyRight™ CMS-1500 Health Insurance Claim Form (02/12); 1-Part Continuous, 1,000/Carton
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
Item # 901-CMS1211
ComplyRight™ CMS-1500 Health Insurance Claim Form (02/12), 2-Part Continuous, White/White, 1,000/Box
Printed with OCR "dropout" red ink on 20# paper, as per government regulations
1,000 per case
Form is "8.5x11"
Item # 901-CMS12W2
Item # 901-CMS122
ComplyRight™ CMS-1500 Health Insurance Claim Form (02/12); 2-Part Continuous with Label, 1,000/Carton
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
Item # 901-CMS122B
ComplyRight™ CMS-1500 Health Insurance Claim Form (02/12); 1-Part Continuous with Label, 1,000/Carton
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
Item # 901-CMS121B
ComplyRight™ CMS-1500 Health Insurance Claim Form (02/12); 3-Part Continuous, White/White, 1,000/Pack
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
Item # 901-CMS123
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