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Medical Forms



CMS-1500 Claim Forms (Revised 8/05) These forms are authorized by the centers for Medicare and Medicaid Services to meet all insurance claim requirements. The revised CMS-1500 allows for reporting of the National Provider Identifier (NPI) number. Imprint your name, address and I.D. number on the snap-a-part forms.

 

Envelopes
If you mail just a couple of claim forms, you can choose from ENV-9960 or ENV-9968. The ENV-9968 is designed to make mailing your claim forms faster and more efficient. If you mail several claim forms, choose the 12 ½" x 9" large claim form envelope. Due to new postage regulations, the words "Do Not Bend" have been removed from the large Claim form envelope.

Don’t see your envelope here?
Please call 800-772-7131.

Medical Forms




MCF-387-2 - Snap-A-Part
MCF-387-1 - Laser
CMS-1500 Claim Form, 81/2" x 11"




ENV-9961
Large Claim Form Envelope, 12 ½" x 9"
Imprint area 1" x 4"


ENV-9960
Small Claim Form Envelope, 4 1/8" x 9 ½"
Imprint area 1 1/8" x 4 3/4"
Window size 7/8" x 4 1/4"
Window - 4 1/4" from left side
1" from bottom

Env-9968
Small Claim Form Envelope, 4 ½" x 9 ½"
Window - 3 7/8" from left side
1 ½" from bottom
Window size 1 1/8" x 4 ¾"

 

Pricing Medical Forms


MCF-387-2 Snap-Part
CMS-1500 Claim Form - 2 parts


Carbonless Imprinted Lot Prices
Qty. 250- $65.85
        500 - $87.35
        1000- $107.75
        2000- $205.30
        2500- $255.41

Carbonless Blank Lot
Qty. 250- $44.01
        500- $62.86
        1000- $77.05
        2000- $151.43
        2500- $188.67

____________________


MCF-387-1 Laser
CMS-1500 Claim Form - 1 part


Imprinted Lot Prices
Qty. 250- $40.69
        500- $51.33
        1000- $62.52
        2000- $113.51
        2500- $139.90

Blank Lot Prices
Qty. 250 - $18.85
        500- $27.05
        1000- $31.70
        2000- $59.64
        2500- $73.06

____________________


ENV-9961

Large Claim Form Envelope
with Imprint
Qty. 100- $53.86
        200- $81.87
        500- $155.89
        1000- $257.29

Large Claim Form Envelope
without imprint
Qty. 100- $30.02
        200- $57.53
        500- $133.76
        1000- $245.94

____________________


ENV-9960

Small Claim Form Envelope
with Imprint
Qty. 500- $92.45
        1000- $109.28
        2000- $211.70
        3000- $280.85
        5000- $427.02

____________________


ENV-9968

Small Claim Form Envelope
with Imprint
Qty. 500-$102.53
        1000- $133.02
        2000- $254.48
        3000- $374.20
        5000- $602.18

Small Claim Form Envelope
without Imprint
Qty. 500- $84.36
        1000- $101.68
        2000- $201.85
        3000- $302.77
        5000- $482.02