Medical Forms and Health Care Claim Forms

Item# 15-0496 Deposit/Overlay Slips Deposit/Overlay Slips, 3" W x 10" H, blue ink on white paper. Price is per 100. $9.00

Item# 67-0005 Welcome-Patient Information Patient information form, one sided, 8 1/2" W X 11" H, Black ink on buff paper. Price is per 100. Quantity: Up to 4 $9.50 Quantity: 5 or more $9.00

Item# 67-0010 Welcome-Patient Information Form Welcome-Patient information form, one sided, 8 1/2" W X 11" H, Black ink on yellow paper. Price is per 100. Quantity: Up to 4 $9.55 Quantity: 5 or more $7.95

Item# 67-0120 Records Release Records Release, 2 part NCR-top white, bottom yellow, 4 1/4" W X 5 1/2" H, Black ink. Price is per 100. Quantity: Up to 4 $9.25 Quantity: 5 or more $8.00

Item# 67-0140 Return to Work Return to Work, 2 part NCR, 4 1/4" W X 5 1/2" H, one side yellow, one side white. Black ink. Price is per 100. Quantity: Up to 4 $9.25 Quantity: 5 or more $8.00

Item# 67-0145 Return to School Return to School, 2 part NCR, 4 1/4" W X 5 1/2" H, one side white, one side yellow. Black ink. Price is per 100. Quantity: Up to 4 $9.25 Quantity: 5 or more $8.00

Item# 67-0150 Medical Excuse Medical Excuse, 2 part NCR, 4 1/4" W X 5 1/2" H, one side white, one side yellow. Black ink. Price is per 100. Quantity: Up to 4 $9.25 Quantity: 5 or more $8.00

Item# 67-0190 Signature on File-Medical (Sticker) Signature on File-Medical (Sticker), white Quantity: Up to 4 $5.50 Quantity: 5 or more $3.95

Item# 67-2005 Patient Information Form Patient information form, one sided, 8 1/2" W X 11" H, Black ink on white paper. Price is per 100. Quantity: Up to 4 $8.25 Quantity: 5 or more $7.00

Item# 67-2010 Patient Information, Ophthalmology Patient Information, Ophthalmology, one sided, 8 1/2" W X 11" H, Black ink on white paper. Price is per 100. Quantity: Up to 4 $8.25 Quantity: 5 or more $7.00

Item# 67-2050 Progress Notes Progress notes, two sides same, 8 1/2" W X 11" H, Black ink on green paper. Price is per 100. Quantity: Up to 4 $9.35 Quantity: 5 or more $8.15

Item# WCMS1500CS CMS 1500 HCFA Claim Form - Laser New Format: One Part Laser Claim Form with space for NPI code, 8 1/2" W x 11" H, OCR red ink on white paper, 2500 per carton. Replaces WHCFA-1500-CS90, WHCFA-1500-CSN90, WHCFA-1500-32-CS, WHCFA-1500-32CSN. Quantity: Up to 2 $57.95 Quantity: 3 or more $55.95

Item# NLCFUB041 NLCFUB041 Claim Form - Laser New Format: One Part Laser Hospital Form with space for NPI code, 8 1/2" W x 11" H, OCR red ink on 20# white paper, 2500 per carton. Replaces NLCFUB921. Quantity: Up to 2 $57.95 Quantity: 3 or more $55.95

Item# WCMS15001 CMS 1500 HCFA Claim Form - One Part Continuous New Format: One Part Continuous Claim Form with space for NPI code, 9 1/2" W x 11" H (including pin feed), OCR red ink on white paper, 2500 per carton. Replaces WHCFA-1500-1-90 and WHCFA-1500-1-N90. Quantity: Up to 3 $57.75 Quantity: 4 or more $55.75

Item# WCMS15002 CMS 1500 HCFA Claim Form - Two Part Continuous New Format: Two Part Continuous Claim Form with space for NPI code, 9 1/2" W x 11" H (including pin feed), OCR red ink on white and yellow paper, 1,000 per carton. Replaces WHCFA-1500-2-90 and WHCFA-1500-2-N90. Quantity: Up to 2 $51.95 Quantity: 3 or more $47.95

Item# WCMS15003 CMS 1500 HCFA Claim Form - Three Part Continuous New Format: Three Part Continuous Claim Form with space for NPI code, 9 1/2" W x 11" H (including pin feed), black ink on white, yellow and pink paper, 500 per carton. Replaces WHCFA-1500-3-90, WHCFA-1500-3-N90. Quantity: Up to 2 $54.50 Quantity: 3 or more $52.50

Item# WCMS-1500-2W WCMS-1500-2W HCFA Claim Form - Two Part Continuous New Format: Two Part Continuous Claim Form with space for NPI code, 9 1/2" W x 11" H (including pin feed), OCR red ink on all white paper, 1,000 per carton. Replaces WHCFA-1500-N and WHCFA-1500-N90. Quantity: Up to 2 $51.95 Quantity: 3 or more $47.95

Item# WCMS-1500-1PS WCMS-1500-1PS HCFA Claim Form - One Part Continuous New Format: One Part Continuous Claim Form with space for NPI code and label, 9 1/2" W x 11" H (including pin feed), OCR red ink on white paper, 1,000 per carton. Replaces WHCFA-1500-1-PS. Quantity: Up to 2 $73.75 Quantity: 3 or more $66.50

Item# WCMS-1500-2PS WCMS-1500-2PS HCFA Claim Form - Two Part Continuous New Format: Two Part Continuous Claim Form with space for NPI code and label, 9 1/2" W x 11" H (including pin feed), OCR red ink on all white paper, 1,000 per carton. Replaces WHCFA-1500-2PS. Quantity: Up to 2 $110.50 Quantity: 3 or more $100.50

Item# WCMS1500U2 (Red) CMS 1500 HCFA Claim Form - Two Part Snap Set New Format: Two Part Snap-Set Claim Form with space for NPI code, 8 1/2" W x 11" H (after tear-off), OCR red ink on white and yellow paper, 500 per carton. Replaces WHCFA-1500-U-290. Quantity: Up to 2 $45.00 Quantity: 3 or more $41.00

Item# WCMS1500U2 (Black) CMS 1500 HCFA Claim Form - Two Part Snap Set New Format: Two Part Snap-Set Claim Form with space for NPI code, 8 1/2" W x 11" H (after tear-off), black ink on white and yellow paper, 1000 per carton. Replaces WHCFA-1500-U-290. Quantity: Up to 2 $89.50 Quantity: 3 or more $79.50

Item# WCMS-1500-1-14 WCMS-1500-1-14 HCFA Claim Form - One Part Continuous New Format: One Part Continuous Claim Form with space for NPI code, 9 1/2" W x 14" H (including pin feed), OCR red ink on white paper, 2500 per carton. Replaces NCCFM1-14. $78.50

Item# WCMS-1500-2-14 WCMS-1500-2-14 HCFA Claim Form - Two Part Continuous New Format: Two Part Continuous Claim Form with space for NPI code, 9 1/2" W x 14" H (including pin feed), OCR red ink on white paper, 1,000 per carton. Replaces NCCFMN-14. $95.00

Item# WCMS-1500CL WCMS-1500CL HCFA Claim Form - Laser New Format: One Part Laser Claim Form with space for NPI code, 8 1/2" W x 11" H, OCR red ink on white paper, 2500 per carton. Replaces WHCFA-1500-CL. $57.95

Item# WCMS-1500C1 WCMS-1500C1 HCFA Claim Form - One Part New Format: One Part Claim Form with space for NPI code, 9 1/2" W x 11" H (including pin feed), OCR red ink on white paper, 2500 per carton. Replaces WHCFA-1500-C1. $57.95

Item# WCMS-1500C2 WCMS-1500C2 HCFA Claim Form - Two Part New Format: Two Part Claim Form with space for NPI code, 9 1/2" W x 11" H (including pin feed), OCR red ink on all white paper, 1,000 per carton. Replaces WHCFA-1500-C2. $57.95

Item# CCFUB044 UB 04 Medical Claim Form - Four Part Continuous New Format: Four Part Continuous Claim Form with space for NPI code, 9 1/2" W x 11" H (including pin feed), OCR red ink on white paper, 500 per carton. $57.70

Item# CCF-M1-20 Continuous Claim Form 1 Part Continuous Claim Form 9 1/2in W x 11in H, No Barcode, Black Ink on White Paper, 2500 per carton $46.95

Item# CCF-MN-M Continuous Claim Form 2 Part Continuous Claim Form 9 1/2in W x 11in H, No Barcode, Black Ink on White/White, 1000 per carton $51.60

Item# CCF-MNB-M Continuous Claim Form 2 Part Continuous Claim Form 9 1/2in W x 11in H, Barcode, Black Ink on White/White, 1000 per carton $51.60

Item# CCF-MNBR Continuous Claim Form 2 Part Continuous Claim Form 9 1/2in W x 11in H, Barcode, OCR Red Ink on White/Canary, 1000 per carton $51.60

Item# CCF-UB92-1 Continuous Claim Form 1 Part Continuous Claim Form 9 1/2in W x 11in H, No Barcode, OCR Red Ink on White Paper, 2500 per carton $46.95

Item# N-CCF-M Continuous Claim Form 2 Part Continuous Form (Carbon Interleaved) 9 1/2in W x 11in H, Barcode, OCR Red Ink on White/Canary, 1000 per carton $54.25

Item# N-CCF-UB-92-3 Continuous Claim Form 3 Part Continuous Form, 9 1/2in W x 11in H, No Barcode, OCR Red on All White, 500 per carton $45.55

Item# N-CCF-UB92-2 Continuous Claim Form 2 Part Continuous Claim Form 9 1/2in W x 11in H, No Barcode, OCR Red Ink on White/White, 1000 per carton $51.60

Item# N-CCF-UB92-4 Continuous Claim Form 4 Part Continuous Form, 9 1/2in W x 11in H, No Barcode, OCR Red on All White, 500 per carton $57.70

Item# WHCFA-1500-1 Continuous Claim Form 1 Part Continuous Claim Form 9 1/2in W x 11in H, Barcode, Black Ink on White Paper, 2500 per carton $46.95

Item# WHCFA-1500-2 Continuous Claim Form 2 Part Continuous Claim Form 9 1/2in W x 11in H, Barcode, Black Ink on White/Canary, 1000 per carton $51.60

Item# WHCFA-1500-U2 Continuous Claim Form 2 Part Uniset Claim Form 8 1/2in W x 11in H, Barcode, Black Ink on White/Canary, 1000 per carton $69.90

Item# WHCFA-10-ENV-SS HCFA Envelopes Touch and Seal window right HCFA form mailing envelopes. 9 5/8" W x 4 1/8" H, window 4" from left, 1 5/8" from bottom. White only. Sold in lots of 500. Choose from 1, 2, 5, 10 or 20 lots only. Quantity: Up to 1 $61.26 Quantity: 2-4 $46.30 Quantity: 5-9 $39.28 Quantity: 10-19 $36.75 Quantity: 20 or more $35.15

Item# WCMENVI UB04 & ADA06 Envelopes Gummed window left envelope for UB04 and ADA06 forms. 4 1/8" H x 8 7/8" W, window 1/4" from left, 3/4" from bottom. White only. Sold in lots of 500. Choose from 1, 2, 5, 10 or 20 lots only. Quantity: Up to 1 $45.50 Quantity: 2-4 $34.63 Quantity: 5-9 $28.27 Quantity: 10-19 $24.62 Quantity: 20 or more $23.32

Item# WHCFA-1500-ENV-SSI HCFA Mailing Envelopes Touch and Seal window mailing envelopes for HCFA forms. 12 1/2" H x 9" W, window 4" from left, 9 5/16" from bottom. White only. Sold in lots of 100. Choose from 1, 5, or 10 lots only. Quantity: Up to 1 $108.85 Quantity: 2-5 $38.99 Quantity: 10 or more $28.12