Page 16 of hcfa cms 1500 health insurance business forms
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ComplyRight Employee Separation Forms (AR0373)
Item #: 901-712163
50 Pack
Size: 81/2” x 11”
8 1/2" x 11"
$44.99
1-2 pack
Save 7%
$41.99
3+ pack
Custom Multi-Purpose Register Form, Colors Design, Small Format, 4 Parts, 1 Color Printing, 4" x 6", 500/Pack
Item #: 901-D609T4
Use with your portable register to capture details on the spot - no hunting for a handy place to write
Preprinted areas simplify write-ups of customer information, salesperson, description of items, payment method & more
Compatible with 4 x 6" portable registers, sold separately
Custom Multi-Purpose Register Form, Classic Design, Large Format, 4 Parts, 1 Color Printing, 5 1/2" x 8 1/2", 500/Pack
Item #: 901-D6104
Use with your portable register to capture details on the spot - no hunting for a handy place to write
Preprinted areas simplify write-ups of customer information, salesperson, description of items, payment method & more
Compatible with 5 1/2 x 8 1/2" portable registers, sold separately
Custom Multi-Purpose Register Form, Image Design, Large Format, 3 Parts, 1 Color Printing, 5 1/2" x 8 1/2", 500/Pack
Item #: 901-D25313
Contemporary design projects a professional image
Use with your portable register to capture details on the spot - no hunting for a handy place to write
Preprinted areas simplify write-ups of customer information, salesperson, description of items, payment method & more
Custom Register Forms, Classic, Cash & Charge 3 Parts, 1 Color Printing, 5 1/2" x 8 1/2", 500/Pack
Item #: 901-D158143
Die cut holes fit most standard registers
Includes personalization up to 4 lines
Imprint Color: Red
Custom Multi-Purpose Register Form, Image Design, Large Format, 2 Parts, 1 Color Printing, 5 1/2" x 8 1/2", 500/Pack
Item #: 901-D25312
Contemporary design projects a professional image
Use with your portable register to capture details on the spot - no hunting for a handy place to write
Preprinted areas simplify write-ups of customer information, salesperson, description of items, payment method & more
Custom Multi Purpose Forms, Continuous, 3 Parts, 1 Color Printing, 8 1/2" x 7", 500/Pack
Item #: 901-D913163
Consecutive numbering available
Promote your business: Personalization includes your imprint plus choice of typeface and standard logo
Imprint Color: Black
Custom 2-Part Numbered Charge Slip Forms, 8-1/2" x 11", 1000 Sets per Pack
Item #: 901-QFW1053801
For internal use in veterinary offices
8-1/2" W x 11" L
2-part, white/canary, carbonless; pre-printed in black and blue ink
Custom Referral Report Form Slips, 5-1/2" x 8-1/2", 100 Sheets per Pad
Item #: 901-QFN160501R
Referral forms for physicians
5-1/2" W x 8-1/2" L
White 20# text stock; printed in black ink
NAHANCO Men's Half Round Display Form, Black, 1 Each
Item #: 901-216469NAH
12/pack
Dimensions: 7"(Deep), 35 x 20 x 6
Style: Torso
$39.99
Per each
Custom 2-Sided Dental Registration and History Forms, 8-1/2" x 11", 250 Sheets per Pack
Item #: 901-QFN105121R
For use in patient charts
8-1/2" W x 11" L
White 20# text stock; printed in black ink
ComplyRight™ 50-State Job Application (Long Form), Pack of 50 (A0019)
Item #: 901-1949613
Written by Employment Attorneys to ensure compliance in all 50 states
Gathers the maximum amount of information and exposes “red flags” without crossing into illegal territory
Includes tip sheet with HR best practices and compliance guidelines
$70.99
Per each
Custom HIPAA Privacy Practice Acknowledgment Forms, 8-1/2" x 11", 200 Sheets per Pack
Item #: 901-QFN155811R
For use in patient charts
8-1/2" W x 11" L
White 20# text stock; printed in black ink
Custom Carbonless 2-Part Dental Diagnosis and Estimate Forms, 8-1/2" x 11", 250 Sheets per Pack
Item #: 901-QFN102621R
For use in providing estimates and treatment plans
8-1/2" W x 11" L
2-part, white/canary, carbonless; printed in black ink
ComplyRight CMS-1500 Self Seal Security Tinted Window Envelope 9" x 12 1/2", White/Blue, 100/Pack (1500LR)
Item #: 901-1500LRQQ
Envelope holds up to 50 CMS-1500 unfolded claim forms.
Helps reduce processing delays.
Right-window reveals only the mailing address.
$48.99
Per pack
($0.49/EACH)
Custom Chiropractic Informed Consent Forms, 8-1/2" x 11", 250 Sheets per Pack
Item #: 901-QFN105101R
Use to provide costs and services to patients
8-1/2" W x 11" L
White 20# text stock; printed in black ink
Custom 1-Sided Insurance Registration Forms, 8-1/2" x 11", 250 Sheets per Pack
Item #: 901-QFN105011R
For use in patient charts
8-1/2" W x 11" L
White 20# text stock; printed in black ink
ComplyRight CMS-1500 Jumbo Health Care Billing Envelope, 500/Pack (1500LR500)
Item #: 901-24581404
This CMS-1500 jumbo health care billing envelope helps reduce processing delays
500 envelopes per box
Form size: 9" x 12.5"
$154.99
Per each
TFP Self Seal Security Tinted Window Envelope 4-1/2" x 9-1/2", White, 500/Box (1500ES)
Item #: 901-1500ESQ
Self seal CMS-1500 right window envelope
HIPAA security tent, 24 lb. bond paper
Accommodates 12 folded CMS-1500 claim forms
$119.99
Per box
($0.24/EACH)
TFP UB-04 CMS-1450 1-Part Health Insurance Claims, 2500/Carton (UB04LC)
Item #: 901-519727
Designed for hospitals to file a medical claim with the patient's insurance carrier
One-part health insurance forms
Contains 2500 forms per carton
$121.99
Per carton
($0.05/EACH)
Custom Carbonless Veterinarian Surgical Consent Form, 5-1/2" x 8-1/2", 100 Sets per Pad
Item #: 901-QFW1302901
Self-duplicating; everything is printed on original and duplicate
5-1/2" W x 8-1/2" L
White self-duplicating carbonless stock; pre-printed in black ink
Custom Dental After-Treatment Instruction Forms, 8-1/2" x 11", 100 Sheets per Pad
Item #: 901-QFN105611R
Use for patient care instructions
8-1/2" W x 11" L
White 20# text stock; printed in black ink
Custom 1-Sided Patient Registration FormFamily™ Sheets, 8-1/2" x 11", 2-Hole Top Punched, 250 Sheets per Pack
Item #: 901-QFN103771R
For use in patient charts
8-1/2" W x 11" L
White 20# text stock; printed in teal ink
Custom Carbonless 2-Part Certificate of Professional Care Forms, 4" x 5-1/2", 50 Sets per pad
Item #: 901-QFN131121R
For certification of care
4" W x 5-1/2" L
2-part, white/canary, carbonless; printed in black ink
