60164 a.k.a. 70164, CMS-1500 Laser Insurance Claim Form, Padded & Imprinted

60164 a.k.a. 70164, CMS-1500 Laser Insurance Claim Form, Padded & Imprinted
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Padded CMS-1500 Laser Insurance Claim Form - Item # 60164

Price

Your Price: $53.00

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INS12 Quantity ? (required) help
Federal Tax I.D. # (required)
Service Facility Information
Service Facility Name (required)
Service Facility Street Address (required)
Service Facility City, State, Zip (required)
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Billing Provider Name (required)
Billing Provider Street Address (required)
Billing Provider City, State, Zip (required)
Billing Provider Phone Number (required)
SHIPS FREE, $53 - 5 | $83 - 10 | $149 - 20 | $354 - 50 | $692 - 100

60164 Insurance Claim Form, Padded & Imprinted
AMA and CMS approved claim form.  Insurance claim laser forms, 100 sheets per pad, single sheet format.  8-1/2" x 11" 1-part laser form on 20# white bond stock, printed in OCR red ink.  Accommodates NPI numbers as mandated by HIPAA. Accepted by most insurance companies.

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