Custom Carbonless 2-Part Advance Beneficiary Forms, 8-1/2" x 11", 250 Sets per Pack
$118.99
1 pack
Save 33%
$78.99
20+ pack
Custom Carbonless 2-Part Advance Beneficiary Forms, 8-1/2" x 11", 250 Sets per Pack
Item #:
901-QFN230181R
Model #:
7QGFM230181R
Brand:
Quill Custom Print
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$118.99
1 pack
Save 33%
$78.99
20+ pack
1 PACK = 250 EACH
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Qty. savings
$118.99
1 pack
10%
$106.99
2 - 3 pack
17%
$97.99
4 - 7 pack
25%
$88.99
8 - 19 pack
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20 + pack
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Custom Carbonless 2-Part Advance Beneficiary Forms, 8-1/2" x 11", 250 Sets per Pack
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Description
This form helps patients make informed choices of whether to receive items or services they may have to pay for themselves.
- Use to provide costs and services to patients
- 8-1/2" W x 11" L
- 2-part, white/canary, carbonless; printed in black ink
- 250 sets per pack
- Notifies patient of services Medicare may not cover and why
- In most cases, eliminates the need for the Notice of Exclusion from Medicare Benefits (NEMB) for voluntary notifications
Specifications
# Up Per Sheet/Page
1
Binding Type
Glued/Gummed
Brand
Quill Custom Print
Carbonless
Yes
Color
White
Customizable
Yes
Form Size
8 1/2" x 11"
Form Type
Insurance
Format
Medical Chart
Holes Punched
No
Lines
7
Media Quantity
250
NCR Paper
Yes
Number of Parts
1
Numbered
No
Package Quantity
250
Personalization
Yes
Security Features
No
Sheet Size
8 1/2" x 11"