Custom 2-Part Snapset CMS Forms, 8-1/2" x 11", 500 Sets per Pack
$296.99
1 pack
Save 27%
$214.99
8+ pack
Custom 2-Part Snapset CMS Forms, 8-1/2" x 11", 500 Sets per Pack
Item #:
901-QFW1471701
Model #:
7QGFM1471701
Brand:
Quill Custom Print
(2 reviews)
Item #:
901-QFW1471701
$296.99
1 pack
Save 27%
$214.99
8+ pack
1 PACK = 500 EACH
Buy more & save!
Qty. savings
$296.99
1 pack
5%
$281.99
2 pack
10%
$264.99
3 pack
21%
$232.99
4 - 7 pack
27%
$214.99
8 + pack
Upgrade to get 5% off, earn points 10% faster and more.
Custom 2-Part Snapset CMS Forms, 8-1/2" x 11", 500 Sets per Pack
Customers also viewed
Custom Carbonless 2-Part Advance Beneficiary Forms, 8-1/2" x 11", 250 Sets per Pack
Item #: 901-QFN230181R
Custom 1-Sided Insurance Registration Forms, 8-1/2" x 11", 250 Sheets per Pack
Item #: 901-QFN105011R
Custom Insurance Authorization Slips, 5-1/2" x 4", 100 Sheets per Pad
Item #: 901-QFN131491R
Custom Insurance Assignment Release Slips, 4" x 5-1/2", 100 Sheets per Pad
Item #: 901-QFN142231R
Description
Accommodates reporting of the NPI number and is approved by the AMA's Council on Medical Services and CMS.
- Snapset form for use by all medical facilities for billing insurance companies, Medicaid and Medicare; aligned with the electronic HIPAA ASC X12N 837 Non-institutional Transaction Standard
- 8-1/2" W x 11" L
- 2-part, white/canary, carbonless
- 500 sets per pack
- Printed on recycled paper
- Option to personalize tax ID#, service facility location and provider information
Specifications
# Up Per Sheet/Page
1
Binding Type
Glued/Gummed
Brand
Quill Custom Print
Carbonless
No
Color
White
Customizable
Yes
Form Size
8 1/2" x 11"
Form Type
Medicare
Format
Medical Complaint Form
Holes Punched
No
Lines
Varies
Media Quantity
500
NCR Paper
No
Number of Parts
2
Numbered
Yes
Package Quantity
500
Personalization
Yes
Security Features
No
Sheet Size
8 1/2" x 11"